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APPLICATION FOR SANITATION PERMIT Permit No. -7_J 57A, " (Complete in Duplicate) Date Issued Applica;ion is hereby made to the SanJoaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordi e No. 49. JOB ADDRESS AND LOCATION... -�----- �� - -- ---- ------------------------------•------------------------------------- 01 117" Owner's ---=-------- Owner's Name--- ------ --------------- ------ Phone..- --------•----------------------- Address--'_r --- --•- •--- ----------------------------------------- ------ Contractor's Name--- _ _____ --.__ Phon _ Installation will serve: Residence A—Ap7tment House ❑ Commercial ❑ Trailer Court ❑ Motel (] Other E] Number of living units: Y_.._ Number of bedrooms __2 Number of baths __(_.- Lot size ------X_J_.?.4_=_________________ { Water Supply: Public system '&__C.ammunity system ❑ Private ❑ Depth to Water Table 44 ft Character of soil to a depth of 3.feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ar pan ❑ Previous Application Made: Yes ❑ No [ w Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep to :J Distance from nearest well------------------Distance from foundation-------------------Material-------------------------------------------_.--. No. of compartments------------- ------------Size--------------------------------Liquid depth --------- -------------.-Capacity---•------------------- Dispos i Fie Distance from nearest wefi....--------------Distance from foundation--------------------Distance to nearest lot line.___-__--_-_---_ Number of lines-1______________________________ __Length of each line-------------------------------Width of trench-------------•----------------_---- Type of filter material--- -------Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well---Distance om,fo ndation_-----` _�__.Distance.to nearest lot line__._��a....._ .� Number of pits._ ---- -..-- Lining material-----------------------Size: Diameter_, .I ___..._-_Depth--.2'....................... Q Cesspool: Distance from nearest well-----------------Distance from foundation..._................Lining material._____._-_.._--.__--.___----_-__-----. Size. Diameter_"l--"------- -------- --- -- ❑ r ---Deptlr = :'--:Liquid Capacity----------------------------gals. Privy: Distance from_nearest well-------------------------------------------------Distance from nearest building---------------------------------------- ___-._-_----..-----__-_---- -_--_.-- E] Distance to nearest lot line-----------------------------------------------------------------------•------------ ----------------------------- -- ---------------------- - Remodeling and/or repairing {descriEaey:__._.___._..__.___________ ---- ' A ------•----•--------------------------------------------------------------------------- ---------- - --- ---------------------•------------------•----------------------------------------------------------------------------------------------•-••------------------------------------•-----••------------ --•--------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--- - -- -------------------------------------------- ----------- -------------------------------------- ------------ e" ar Contractor) r By:. ---------------------------------------------------------- (Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE REVIEWEDBY------------------------------------ ------- - ---- ----------------------------------- -----•------------ ----- --- DATE-------- ------ -2- BUILDING PERMIT ISSLIED---"---------- ----------------------- ---------------•------------------------------------------ DATEt -- ----------------------------------- Alterations and/or recommendations:---------------------------------- ----- -------------------------------------------------------•--------------- --- �-------------------------- ----------- --••--••-----------•------- ----- -f --• = 1-&- --- --N :: •--------------•--._-.---------- ..----•----••---•----------- ------------------------------_-.-_.___-.__.._-----.----------------------------------------------- ------------ _-._._...___._...._.__...__..___.......___..__ T FINAL INSPECTION-BY:---- .. --------------------- --- ...... Date---- O ---- ------------------ --------------------------------- � i " SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak S+ree+ 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California r5' 9-2M 145446 ATWOOO 12-54