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APPLICATION POR SANITATION PERMIT Permit No. :_ (Complefe in Duplicate) .� Date Issued ------�--- .fs : 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. JOB ADDRESS AND LOCATION.___ '' c* _ --- ---------------- Owner's Name G- ------------------ Phone =" Address.. - - --- -- --- �lrw - -- {---------------••--------•--•------------------------------------------•------------------- Contractor's Name - --------------------------------------------------------- Phone -------------- Installation will serve: Residence..WApartment House ❑ 'Commercial [a Trailer Court ❑ Motel [] Other ❑ Number of living units: __ '_ Number of.bedrooms --------- Number of baths - Cot size --•----------•----------- Water Supply: Public system ❑' Community system ❑ Private Depth to Wafer Table 4� ft. Character of soil to a depth of 3 feet: Sand Gravel Sand Loam Clay Loam Clay rte_ p ❑ ❑ Y I] Y ❑ y ❑ Adobe��Hardpan ❑ Previous Application Made. Yes [] No qL_ New Construction: Yes & No ❑ TYPE:OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from; nearest welll�d__--_Distance from f$undation___A0!__.Material----- [��i-- No, of compartments_-__.�r- Liquid d --------_Size__:__�A�--------------Li e th •r q I? -�- ----._Capacity- ------ Disposal Field: Distance from!;nearest well-------------_--Distance from foundation_---_`- ------------Distance to nearest lot line-__.__.-_-_-_--_- © Number of lines------------- - -----------------Length of each line----------------------------.-.Width of trench Type of filter 'material----------------------- _DepM of filter material--------------------- Total length-----------------------.---------------- �: Seeppaa�ge Pit: Dp Distance tonearest well__ e/ __Distance from foundation---� _O _ ---------- to nearest lot line..-_-./0-!-_ Number of its y.........Lining material__. Size: Diameter ��De th.-_ � Cesspool: Distance from,; nearest weft_---------------Distance from foundation...------..._.`.-__:Lining material-----------_____-------------------- El ._ ------•----- -------'-------------Liquid Capacity----------------------------gals. `� Privy: Distance D stanDee mromr nearest well................?,_- -- `�'•i ---- ------------------ Depth r I ------------------ ---Distance from nearesr building--------------------------------- El Distance to nearest lot line_ •--------------------------------------------------•------ 4. Remodeling and/or repairing (deslcr.ibe)--------------------------------------- I --------------------------- -_ --- ---••------•-------------------------------------------------- ----- ------------------------------------------------------------ ------------•--------------------•--------- ------------•-----------------------------------•-- -----------------------------•--------•------------------------- --------------------------•----•-------•---------------•--'--•------------------------•------- ------------------------•--- ---------------- - ---------------•------------------------------------ ------------------------ -------------•---------------•--- ---------------------------------••-•-•---------!-------------------------------------------------- I`hereby certify that I have prepared this application andthat the work will be done in accordance with San Joaquin County A ordinances, State laws, and rules and regulations of"the San ,Joaquin Local Health District. 5i ned � { g c - -x -- ----- ------------------------------------------------------------ 6 . (Owner and/or Contractor) J. By: L ---------------------------(Title)------- K---------------- ot plan, showing size of lot, location of system in relation to"wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------=------- ------------.---- -- -4 ._-'---------------------- ------------------ DATE----- REVIEWED BY--------------------------------- ---------------+' DATE. BUILDING PERMIT ISSUED. " -------�•---•----•- ---------- ------- ------------ ----------------------------•------------ DATE------------ ----- ..----------------••- Alterations and/or recomme dations:----- _ ,--------------- -------------------------•-•----------------- -----------•----------- -•------- f� ---- ---- - ------ - .. -- _ ----4- --- ----- ............................................ ---------- _ FINAL INSPECTION BY---------------- .----------- ---• C ,. ------------'--- Date------ ---------- - i � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wesf Oak Street 132 Sycamore Street 814 North °°C" Street Stockton, California Lodi, California Manteca, California Tracy, California r E5-4 +4s446 ATWOOD q „