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APPLICATION FOR SANITATION PERMIT Permit No. !sem (Complete in Duplicate) �7 // Date Issued ------------------•__b 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 with11 ounty Or ante No 5 JOB ADDRESS AND LO TI N .... --- ------ Owner's Name------------ --------- ------- Phone _ �—~ Address--•-----------------------�aJ• - F:� -------------------------•---•----•-•--•-•------------------------------------ i ------------------------- -;F6;Contractor s Name--- - ----- �a� -------------- Phone//r4 -.__ ,1 - --- 0,,7 Installation will serve: Residence % Apartment Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __:_ Number of bedrooms __.`Number of baths --1---_ Lot size _____ ---Q-. _ _., �--- ----------- Water Supply: Public system ❑i!Community system ❑ Private 9 Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes 0 No%Q New Construction: Yes ❑ No4 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) F Septic Tank: Distance frromom 5eP No. of compartmentsnearest well-.4.S-_----Distance from foundation---Ar---------Material-_-___- _ _ ___ __ -----------;17 I ___�___________._.Size___3&---1,Qa------Liquid depth—'517--_.---._.__Capacity._ P Disposal Field: Distance from~nearest welt----- _----- _-Distance from foundation--------------------Distance to nearest lot line:_---_--_-_----_- ❑kiUS't Al Number of lines----------------_--------- ------Length of each line-----------------------------Width of french------------------------------ Type of filter material-------------------------Depth of filter material __.-------------------Total length------------------------------------------ r Seepage Pit: Distance to ne'arl---------------------__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: Diam - - -De Depth - ----.-Liquid Capacity .._ __.gg__l Privy: Distae froml'nearest well---_-------------------------------- __--------__Distance from neaebuilding.._._____.-___________________._...__.___s__. Distance .. - to nearest lot line--- --------------------------=--------------- ------ ----- ---------- Remodeling and/or repairing (describe):-------- ------- -- --- ------ ----- ---- ------------- - --------- -------------------------------- ----.--.- ------------------------------------ -------- - ---------- -- ----------- ------------- --------------•-----.-.------------------•---------------;4--------------------- ------------------------••-•---•--••-------••----•---------------------------- -------------- 4 - ----------•----------- ------- ------ -----------------------------•-•----------------•---------------------------------------------------------------------•-----------------•-----••------------•--• --- -•------- I hereby certify that I have repare this applicatio and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rt s and r gulations oft San Joa uin L I Health District. (Signed)----------------------------------- ---- ---- -------- ------------ --- --- -- ---- ------- ------ ----- --- " ------ -- ----- - wner and/ Contr ctor] • �Ti TiBy .. ------=---- --- --- --- - { Ile]- F --- -- (Plot plan, showing size of lot, locat' of system in relation to wells, build gs, etc., can be place n reverse side). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----_I--------- DATE------_ I REVIEWED BY - - - --- ....... DATE -- --- BUILDING PERMIT ISSUED------------"--•----- ------------------•--- ---- DATE.----- ------------- Alterations and/or recommendations:------------------I._......... ,M ---I---------- - - - -- -------- �i ---------------------------------------------------------- ------------------------ ----------------------- ----,--------------------------- --------------------- ------•-.--I-------- FINAL INSPECTION BY:. — -------------------------------- Date f�"--- -- ------------••-------------------- --------------- a - i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+reet 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California q Lodi, California Manteca, California Tracy, California E5-9-2M 145446 ATWOOD 12-54 ,