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APPLICATION FOR SANITATION PERMIT Perrai'r (Complete'in Duplicate) Date Issued ------------ A �plica+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 Ourdin ce No. 54 JOB ADDRESS AND LOCATIOP... --------- .. .. ...... -- ------ -------------------------- Owner's Na4n _____ ----- ----------- ------------------------ ------------------------------ ----------- Phone..?--- -- Address. --- ------------------------------ ------------------------------------------------------------------------------------ Contractor's Name_-------- ------ 'r--------------------------------------•-------------------------------- Phone--- Installation will serve: Re i ence Apartment House E] Commercial Ej Trailer Court E] Mofel 0 Other E] Number of living units: umber of bedrooms /-_- Number of baths /---- Lot size AZ ----------------------- Water Supply: Public systemV Community system E] Private 0 Depth to Water Tablez-47ft. Character of soil to a depth of 3 feet: Sand [] Gravel E] Sandy Loam E) Clay Loam El Clay I-] Adob Hardpan 0 Previous Application Made: Yes Ej N?-V New Construction: YeAr No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T nk: Distance from nearest well__ ____-_-___Distance from foundation________________._ Material__-_________._..____..__---___________...._-__-.. No. of compartments------------ -------------Size---------------------------•---Liquid depth---------------- Capacity----------------------- Disposal F" cl: Distance from nearest well_____.__..._._.-Distance-from foundafion---------------- _Distance to nearest lot line---____-.__---_-- Number or lines----------------------------- 1--Length of each line--------------------_------.Width of trench.---------------------------------- ''*l Type of filter material-_-_. --o—_ JA0 Depthn of f-Ifer. tial______________---------Total length____________.___:::---------------------- T ' Tle" fou a p. e it: Distance to near, I fr ------ See est well- 1) sf c6 r fou a�ion,,.,/�,�_------ to nearest lot line____�� V I -.-; < Number of pits-----/-r-----------Lining maters z( 'tameter,?------------------DepfI1_._1�0W___ ��_b &/ 1. ar Cesspool: Distance from nearest well-----------------Disfa e from f dation....................Lining material-__..:-_-__-__--__._,__.____________. Capacity... _,, ------- S�ze: Diameter------- ------ Privy- Distance from nearest well - ----------------------------------------------Distance from nearest building____.__.___----------_------------- -. �r ❑ uilding----------------------------------- - 17 Distance to nearest lot line_________________________________________________ - ------------------------------- --------------------------------- - Remodeling and/or repairing {describe):__ -- ------ A-451 -1 --------------------- ------- ---------- ----------V-1----------------- ------------------------------------- ------ . . .......e-- ----------------------------- ------------------------------------------------------ -------------------------------------I---------I--------------------------------------------------- -- ------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S laws, andrules and regulations of the Son Joaquin Local Health District. (Signed)..... ------------ ------------------------------------------- ---------------------- (Ownerand ---------- ...... /or Contra'd or) By:--------------- ----------------------------------------------------------------- ------------------- J 40 ----------- ------ -- - ------------------- �ere�y certify 0 (Title) ;r 0 ---x- --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be pu'ad n rever4 si: FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------ ........ - _C5�------------------ -------------- -------------- --------------- REVIEWED BY------------------------- - ------------ ----------------- -- ----- --------- - - - -V�b DATE -6- ---- ----------------------------------------- DATE------------------------------- BUILDING PERMIT ISSUED-------------------------- -- --------------- --- ----------- DATE Alterations and/or recommendations:_..._baj -- P ------------I 4-1)AA-A., - ---------------------------------------------------- ---------------------- ---------------- -------- --------------------------------------------------------------------------_------------- ------------------------------ ----------------------- -- -- ------ --------------------------------------------------- -------- ------------------------------------------------------------ ------------- ---------- ------------= ----------�,7--------------------------------------------- ---------------------------------------------------------- --- ------------------------------------------------------------------------- ------------------------- -----%- 7----- --------------- ----- ---------- --------------------------------------- ---- ------------------------------------- ------------ ---------------------------------------------------- FINAL INSPECTION BY:.-- ate___ - ------------------------------------- D --------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 4% 130 South American Street 300 West Oak Street 132 Sycamore Street e!4 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California �71 IaS446 ATWoUo 1254