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t APPLICATION FOR SANITATION PERMIT Permit No. ----- // '(Complete in Duplicate) �/ Date Issued ----------------------- Applica+ion is hereby made to the San.Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOBADDRESS ANVeLOCATI'ON---- A- "� t `"�'x '�------; ---------------------------------- --•----------------------------------------••-- Owner s Name l -------------- --------- - Phone.---••------------------------------ Address--------1 f -� - -----------------------------------------------------------------------•-----------------------------------------••-------.._-.._..------------ Contractor's Name_9�. ---------------------•• ---------------------- - --------------------------------------------------------------- Phone----------------------------------- Installation will serve: 'Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [j Other r ❑ Number of living units: __1�____ Number of bedrooms ---I--- Number of baths J---- Lot size __� ------- --5--; _________________ Water Supply: Public.system ;4ommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Lo;'Z Clay Loam E] Clay El Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fee Septic/ ank. Distance from nearest well__- Dista:yGa fro fo adation/f�_____________ ateriI__ ___ __ __.__.___._.__._ _ __._,-._-_.__. No. of compartmenis.....•____ _ __._.__._Size4 � _ ._ --r--_Liquid odepith_ ___ __ _____________Capac,ty.__ _ �___ � _lDistance from foundation_ �f"` ---Di'stance to nearest lot line_ �_n!°�s" Dispos Fie4d: Distance from nearest well ..._ _ �a--�-- �- �f�F� P Number of lines___________.- - -.-. ._Length of each line---------... Width of t ----- __Z_'T �� y----- --------- Type of filter materia`L�. ,sDepth of filter material_._.._.__ _____._Total length___.------ _____________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__.____.________- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-------------------_------------. Cesspool: Distance from nearest well.----------------Distance from foundation------------------- Lining material---------- ______________________" ❑ Size: Diameter------------------ -------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--------------.---------------------------- ❑ Distance to nearest lot line-------- - -----------------•--------------- - -----------------_..---------------------------------------------------------------- --------- V Remodelingand/or repairing (describe):--- --------------------------- ------------------------------------------------------------r-----------------------•------------------------- ---•---I-------------------------------•-•-•--------------•--•------- ----------------------------------------------•--•------------------------------•-----------------------------•----.----•-------------------------- -------------------------------------- ----------------------•---•-----------•---------•--------------------•-•-----------------•----------------------------•-------------------------=---------•--------------------------- -----------------------------------------------------••--------•-----------•-•------------.....--------------------•-•------------•--••--•------------------------------------------------•---------------------- ------------ 1 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 requiations of the San Joaquin Local Health District. a W. Sined � � !` �`e �- ------------------------------------------------------Owner and/or Contractor) g ) --------------------------- --- 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-----•----------- --------------------------------- - . DATE --- -- REVIEWED BY------------- -a.---- - ------ ;� _---------------- -----�- ------------------------------------- --- --- BUILDINGPERMIT ISSUED----------� - -------------------- ---------- -----------I------------------------ ----------•-------•-----•---------------------------- DATE---- Alterations and/or recommendations:._-____._.............._ J --.._--••---------------------------- -------------------------------------- --- --------------------------- --------------------------------- ------- ----------- --------•--------------------------•-----•-- FINAL INSPECTION BY:. -l/--- ------- --------- Date-------- - ------------------------------------- --- ---------------•-•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Er;–t;-2M 745446 ATWODP 12-sa