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APPLICATION FOR SANITATION PERMIT Permit No. .- ..___!�... (Complete in Duplicate) Date Issued ____________ 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....... _/_ _ --------------.S v _Y � ••�---C.a �--�-`------------- Owner's Name------- __I - / --- Phone.-------------------•-- - - 'd---- -•----------------------- l -------------------------------- Contractor's Name---- ---- • $ ---------------------------•---= Installation will serve: Residence 5d_ Apartment House ❑ Commercial ❑ . Trailer Couht ❑ Motel ❑ Other ❑ Number of living units: I------ Number of bedrooms ,_ Number of baths `__. Lot size ......� _._. --1_ Q_--______________ Water Supply: Public system ✓, Community system ❑ Private ❑ Depth to Water Table�CJ_ ft. Character of soil to a depth of 3 feet: Sand [❑ Gravel ❑ Sandy Loam ❑ Clay.Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 2t 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 well________ .. _________Distance from foundation.___ -_._____.____.Material-________.___--.______..______ -__.___..____.__. of compartments--------------------------size-----------------------------�__Liquid de th__.__--_--._..___._______-Capacity Disposal Field: Lance from nearest well.............._-Distance from foundat ion--------------------Distance to nearest lot line----------------- ❑ er of lines------------------------ ----------Length of each line--------------- ------...Width of trench---------------------------------- T pe of filter material-------------------------Depth of filter material-----------------------Totallength---.---••--------------------------------- / Seepage Pit:, Distance to nearest well......A`#U_D--tante from foundpfiion__,5';_;�_ -___r__.Distance�to nearest lot line___ /8_______ \ l5�! Number of pits..../-______________Lining material---(f&1_gfA4 e: Diameter____ - Depth Cesspool: t Distance from nearest well_________________Distance from foundation------------------- Lining material-------------;.________.______.__-_. 4 ❑ Size: Diameter-----------------------------------Depth----------------------- ------ ------ ---------- Liquid Capacity---------------------------gals. Privy: Distance from nearest well __________------------------- ---------.----____Distance from nearest building._________.___._________-_________.___.._. ❑ Distance to nearest lot line----------------------------- --------------------------------------------------------------------------------- Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------------------------------•--------------------------- --------------------------•----------------------------------------------•-----------------•----------•--•--------•-------.._.__.._....-----•-----------------------•----------•--------------------------------------------- I hereby certi hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St a la ; and rules and regulations of the San Joaquin Local Health District. (Signed)---- - r�r =------ Owner and/or Contractor) BY. ------------------------------(Title)-- --- - - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). y FOR DEPARTMENT USE ONLY yy APPLICATION ACCEPTED BY-- ----- --------------- :.�---- ------------------------------------------------------ DATE---------- •------- REVIEWED -BY--------------------------------------------- ----- ------ -- ------------------------------------------------------------I DATE--------- ------ BUILDING ----BUILDING PERMIT ISSUED------------------------------------- -------------- DATE---------..._-� --` - `- Alterations and/or recommendations-------- ----------------- - ---- - - ------ ----...------------------------------------------------•-----•--•-- --- �r- ---------- s - x �.�.. ........ --------------•--• ---•---------------------------------------------------------- 2 -................... --------------------------...........__..--------------._.--------------------:---------- -- --- --- j--•----•------- •-------•----------- ------ --- ---------------------=--------------- FINAL INSPECTION BY:. - r�.,�-------------------------- -------------- Date------.. �- ---_ --7 -c5----- ---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Stree4 814.North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California EE-9 149446 ATWOOD