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APPLICATION FO,,�ANITATION PERMIT Permit No. ..... __-" _-" �. (Complete in Duplicate) Date Issued ----Z, 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 Cour6 Ordinance No. 549. JOB ADDRESS LOCATI ��_'_-�" i ------ ----------- --------- ---------- -A- / Owner's Name-------- --- --- •-- Phone.- LOCA Y -36 _ -------------------------•---•---------------•--•------ --------- ----------------------- -�--------- -- ...Address... = ------ Contractor's Name--------- -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -"J""-" umber of bedrooms ". _. Number of baths ._f'--- Lot size -------------------------------- Water Supply. Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ AdobeP/Hardpan ❑ Previous Application Made: Yes ❑ No VNew Construction: Yes VNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Taj: Distance from nearest well---------""------"Distance from foundation--------------------Material-------_-.---------------.--------------------.-. No. of compartments----------- - ------------Size----------- --:---Liquid depth--------------------- ----Capacity------- -------------- Disposal Field: Distance from nearest.well--------------- Distance from foundatiison--------------------Distance to nearest lot line----------------- Number ---.- -"-"-.Number of lines-------------------------------- --Length of each line------------------------------Width of trench---------------------------------- '"` Type of filter material----- --- ------""-"--Depth of filter material-------"-"--"__-"""".Total length"--.--_._______________________.--- Seepa Pit: Distance to nearest well____-N" _.-.-__Dista-� .. dation"-""fd".---------Distance to nearest lot line---4z-------- Number of pits-----t---------------Lining mate ial._ - -- -Size: .Diameter__- �.-----_--_--.Dept h.-- --------------____-- Cesspool: Distance #rom nearest well.------_._"""..__Dista oundation------------------- Lining material--_.-..-.----_-_---.---.-------"----. ❑ Size: Diameter-------------------- ----------------Depth-------- Liquid Capacity ------------- F-1 = ----gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building----------------------------------------.-- �1 nearest Distance to t---ine"----------------- ------'-------- ------------------- ------------------ ---- - ------------ e ----••-- Re deling and/or repairing (describe): '---------'" -------•---•---------•------------------------------•--- ----------------------- --------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------•---------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)_ ry •----------------------------(Owner and/or Contractor) ' le �'' .............................. BY� - ---- (T1t ) --------- (Piot plan, showing size a lot, location of ystem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY. APPLICATION ACCEPTED BY-" ------------------ ------------------- DATE ----------------------------------------------------------------------------------- ----------------------------------------------------- REVIEWED BY-------------------------------- DATE ------- ---- ----- ----------------------------------- ------- BUILDINGPERMIT ISSUED-------------------------- -------------•------ f7ATE-----DATE-'----=r------------------------------------------ Alterations and/or recommendations--------------------- -- ---...... 3"`------•-----•------••--------------•---------"- 4 ----------------- ------------------------------- --------------------- -------------------- ----------•----------- -------- ---- --------- - -- -- ----'.� — --------- = ------------------------------------ ------ ---- --------- --------- ----------- -------------------------------------------- - - --------' -- ------- --------- ----------------- -------"------- •-- -------- --------------------------------•------- ------------ f� ------ -------------------- Date------- -�-��-----•------------------------------------------- FINAL INSPECTION BY: -------- """"-_ --- - tr _ } SAN JOAQUIN LOCAL HEALTH DISTRICT .130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Lodi, California Manteca, California Tracy, California Stockton, California . ES--9-2M 145446 ATWOOD 12.54