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APPLICATION, FOR SANITATION PERMIT Permit No. (Complete in Duplicate) IM Date Issued 4T ,, G ca+ion is hereby made to the San Joaquin Local Health District fora aermit to construct and install the wo I� application is made in compliance with County Ordinance No. 549. p k herein described. JOB ADDRESS AND•L CATION__________ _ ----------- Owner's Name. _---- Phone._ d --------- = ------------- Address------------------- F-------------------------------------------- -- Contractor's Name_.. - p- = =- = -- _== ===_ _ ---------- ------ -----------------•----- Phone____. Installation will serve: Residence I� artment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: _/_._ Number of bedrooms _. / / x ,j1. f Number of. baths Lot size ______________________________/`�� Water Supply: Public sy`sterr[] Community system ❑ Private'�epth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑_:Sdnd'y Loam Cla Loam .� ^/ Y ❑ Y. ❑ Clay ❑ Adobe© Hardpan ❑ Previous Application Made: Yes ❑ No R" New Construction: Yes ONo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ahk: Distance from nearest well•-6-- ?�SFiefnce f m ndation__._ 77_f®_.. . No, of compartments------- f--------Size---._ ------- --__----Liquid depth------ 7�_----,._Ca aci Dispos loField: Distance from nearest w II • .- /ape#rom foundation__ _ _�--- rk8-to nearest lot line._ 2 � Number of lines___..___--_—�..,-___ �._�Length`�of each line_:__._--I. ___. Width of trench----JM�-__------ Type of filter material__-_ _. ._•._-. . e th_of fiiter ` ' �" IM ------------ ,.,•.., p ,.material------��- - �----Total length---•--------f'�--------------------- pg Seepage Pit: Distance.to nearest well____--____.__1-_--_Distance from foundation------_-------------Distance to nearestjlot line__-_-._____-_____ D�1 ❑ 'Number'of pits----------------------Lining material-----------------------Size: Diameter--- ---------- --------Depth__I�_..------- ----- II ------ Cesspool: Distance from nearest well---_-------------Distance from foundation------------------. Lining material____-___�______._- ' ❑ Sizo: Diameter Depth -------- - --------------Liquid Capacity --- ---------------------- Privy: Distance from nearest well----------------------------- -------------------Distance from nearest building 11 ❑ ------------------ Distance'to nearest lot line________________ -,If, Remodeling and/or repairing (describe):-------- -------------------- - ----------------•-•---------------•------------•-------- ---------------------------•---•-------------------•---------------••--------------- I ------------------------------ -----------:_ ---------------------•------------------------------------------------------------------------------------------------------- 11 I hereby certify that I have prepared this pplication and-that the work will be done in accordance with Sari'Joaquin County ordinances, State Taws, and rules and regulati-ns of the San Joaquin Local Health District. 4 (Si ned 1 9 } .; ------(Owner afla/or Contractor) Tale _ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse sid�iI). FOR DEPARTMENT USE ONLY jl APPLICATION ACCEPTED BY---_----- DATE__._-, IN REVIEWED BY------------------------- --------- = ti DATE----------- ---- ---------------------------- ---------------------------------------- BUILDING PERMIT ISSUED --------------- --------------- DATE--------------•-----' -1� ------------------------------- Ataratians and/or recommendations:-.. -ry ---- ------- ---- ---•-----------------•-----------------•------------------------------ '-. � ----------------------------- Imo- --------------------- ------------ ---- ------- --- -----------------------------------• ---------------- -•------------------ I-.. -------------- ------------------------------------ --- IM FINAL INSPECTION BY:.... = . •------------------••--- Date-- .... _`:._ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North ijC" Str*et Stockton, California Lodi, California Manteca, California Tracy, CEE.lifornia ES---g-2M 145445 ATWOOD