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AOR OFFICE USE I . ---------------------------------------------------- APPLICATION FOR SANITATION PERMIT Permit No. ------------------------ ----- ---- .�, (Complete in Duplicate) ' Date Issued ----------------------------- This Permit Expires 1 Year From Date Issued -------------------- Application 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 P o. S49. 4 ----- --------------•-•-- ------ i --------------------------------------------------------- JOB t ADDRESS AND CATION � kY Owner's Name---- . --------- --------------------------------------------- Phone------------------ �------------ Address-------_-------- ----------Address-------_-------- ---•-_------------------- �� A -- -------------•----------------------------------••--------------------••----------------•- � -/�2 Contractor's Name -------------- ------------------=------ Phone ,1 Installation will serve: Residence O�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -/-- Number of bedrooms -;:;;?- Number of baths ___/_ Lot size ______-:57;��-,x- -- ~.---------------- Water Supply: Public system [z Community system ❑ 'Pr.ivate ❑ Depth to Water Table,' ft. . t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam El Clay El Adobe �lardpan F]_ q:.$ { Previous Application Made: (If yes,date-1q: .) No I] -New Construction: Yes ❑ No �HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Tank: Distance from nearest well_____________-__Distance from foundation------------------_Material------I.........-____..________---------___-_. No. of compartments----------------- -- -----Size--•---------------- ------------Liquid depth--------------------------Capacity------------------`--- ispos I Fi d: Distance from nearest wel- _ . •_ __ Istance from foundation " Distance to nearest lot lines"' Number of lines____ __ ____________ Width of trench_____.. ___ _----__-.--Length of each line---- --------- - of filter material_ "Depth of filter material__ ` -Total length-------------------------- ------- ------- ___._ Seepage Pit: Distance to nearest wells-e�''� _-Distance f om foundation__ Distance to nearest lot line__._ ____ ❑� Number of pits.... __ _ Lining material_ Q C/ _Size: Diameter__ .---- _Dept h-------- , _ -------------- Cesspool: Distance from nearest well-----------------Distance from foundation.--------------.-__.Lining material..._________------__.________________. ❑ Size: Diameter---- ° '.----------------------------Depth--------------------------------- ------------------Liquid Capacity----------------------------gals, fPrivy: Distance from nearest well____________________-------------------------- Distance from nearest buildin , � f 9 - -------------------=------------ ❑ Distance to nearest lot line-- - ---------------------- --- -------------' Remodeling and/or repairing (describe):_.------------------ ---------------------------------'---------------•-••----------------------------------------------------- ------ f ---------------•-•-•-----------------------------------------------=--------------------------------------------------------------------- ---•------------------------------------------- ------------------------------------ l j F -------------------------------------------------------------- ----------------------------------------------------------------------------------- ----- ----------------------------- ------------------------------------------------------------------------------------------------------------- ------------------------------------------- ---- --------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,&t.ews and rules a regu ions of the San .1aa Local Health District. (Signed) ------ ---- ----- ----- --72;�,Id�ings, .fc., {O. and/or Contractor -- - sy:. (Tit-l-- Title) (Plot plan, showing size of lot, location of system in relation to well can be placed on reverse side). FOR DEPARTMENT USE ONLY I _ APPLICATION ACCEPTED BY----- ----------- ------------------------- DATE------ 07---------------- REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---- ----------------------------------- ------------------------------------------------------------ DATE----- -------------------------------:----------------------- Alterationsand/or recommendations:------- -- ----------------------=------------- -----------------------------------------------•--------------------------------------------- ---------------- -------------- -- -------------------- ------ ---------------------------- --------------------------------------- ----------------------- --•----------------------------------•-------------------------------- I ---------------- ----------•-----•-------------- ---------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- --------------- - ---------------------------- - - ------------------------------- ------ --------------------------- --------------------------------------------- -------------------------------------------- FINAL INSPECTION BY:------ - ........... Date--.--- -------------------------------------------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E.Hozellon Ave. 300 West Oak Street 4 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California w Manteca,California Tracy,California,-. F.P.CO. "ri.'w