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APPLICATION FOR SANITATION PERMIT Permit No. ------------- <br /> (Complete in Duplicate) Date Issued <br /> _�_%- <br /> Applica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. S49. <br /> JOB ADDRESS AND CATION_�,P_ �. 3- <br /> - -- - ------------------------------------------------------------------- <br /> Owner's Name---- - ----- -------------------------- ------------- Phone.------------- <br /> - ------- ------- ------------------------ - ------------------ ---------- ---------------------- <br /> Address................... ------ - -- -- --- -------- ­ --------------------------------------------------------------------------------------------------------------------------­... <br /> Contractor's Name-------------------- ---------- -------- ----• ------------------------- --- ---------- ------------------­-------- ------------ Phone----------------------------------- <br /> Installation will serve; Residence A Apartment ouse E] Commercial 0 Trailer Court El Motel El Other El ' <br /> Number of living units: -------- Number of bedrooms -------- Number of baths _1--- Lot size a-- ---------------------- <br /> Water Supply: Public system El Community system El Private x Depth to Water Table ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam Ej Clay 0 Adobe V Hardpan ❑ <br /> N) <br /> Previous Application Made: Yes D No & New Construction: Yes Ej No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Si, tic Tank: Distance from nearest well________________Distance from foundation--------------------lvlaterial__.------------------------------------------------ <br /> No. of cc�7paTtm_ e`nf_s____�---------------------Size--------------------------------Liquid dep. <br /> n ' th--------------------------Capacity----------------------- <br /> Disposal Field: Distance from nearest weal.................Distance from foundation--------- ..........Distance to nearest lot line----------------- <br /> 171 Number of lines-------------------------_-_....._Length of each line---------- ------ ------------Wiclfh of irench.--------------------------------• <br /> - <br /> Ikk Type of filter material--------------- ---------Depth of filter material_._____--_--. --------Total length___-----------._-_--_-___.--.-_.-.--.-.- <br /> Type <br /> Seepage PittAnce to nearest well___,;5---<2--------Distance from n io rP_ --- cloistance to nearest lot line---34)------ <br /> n <br /> umber of pits-----./ --Lining maferial�L�_ . r. Depth---------- <br /> Cesspool:��Dulsfance from nearest well-----------------Distance from Poun d a fli o n------ .............Lining material-______.._----_-___.-------_-_--__-_. <br /> ❑... _.. _.,--.Size:- <br /> aterial---------------- ------------------- <br /> -.,--.Size.:- Diameter---------------------------------------Depth----------------------------------------------------Liquid Capacity.--------------------•------gals. <br /> , , ­ - . —- <br /> Privy., Distance from nearest well-___________________________-____________________Distance from nearesf building------------------------------------------ <br /> El Distance to nearest lot line----------------------------- ------------------------------------------------------------------------------------- ------------ ------------- <br /> Remodeling and/or repairing (clescribe):_W----- <br /> -- ---------------------- --------------------------- <br /> ------------------- <br /> -------------------------------------------------------------------------------------------------------------- ------------------­----------------------------------- ------------------------------------------------------- <br /> ---------------------------------------------------­-­----I----------------------------------------------------------------------- ------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------­­---------------------------I—--------------------------------------------------- ------------ - -------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State . si and rules and regulations of the San Joaquin Local Health District. <br /> �,)19`w <br /> (Signed)........ --------d --- <br /> _- -�_ -----------------------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By:------------------------------------------------------ ----------------------------------------------------------------------------(Title)-------------------------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------- <br /> Y----------------- -------------------------------------------------------------------------------- DATE------------------ --------------------- <br /> 5- -- --- ---- -------------------- <br /> REVIEWED BY-------------------------------------- ----------- ----------------- -------- ------------------- DATE <br /> BUILDING PERMIT ISSUED--------------- -------------------- -----------. . DATE-------- _------------------------------------------------- <br /> Alterations and/or recommendations:------- - •------------------ ­------------------------- ------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------­------------------------------- ----------------------------------------------------------------------- <br /> --------------------------------------------- --------­­--------- -- - -------­ ­---- ------------------------------ -----------------------------------------------------------------------------------------....... <br /> -------------------------------------------- ------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------- ------ ----- --------- ---- -- -- ------------------------------------------------------------------------------------------- ------------------------------- <br /> FINAL INSPECTION BY:- ------- ------------ -f---- --- Date--4?7�-#OZ/---- �l- <br /> ----------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9 145446 ATWOOD <br />