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APPLICATION FOR SANITATION PERMIT Permit No. _ ./.4. --.... (Complete in Duplicate) /SC 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------ ---- -- Owner's Name = -------------------- - Phone. .,t -------• ---- ----------------------------•--------..------------- `-------- Addressj, Contractor's Name...--- •- ------------ - - ---- -- - --- ��------ -------- ------------ Phone.-f r Installation will serve: Residence Xj Apartment House ❑ Commercial ❑ Trail r ourt ❑ Motel ❑ Other ❑ Number of living units: __l____ Number of bedrooms 3----- Number of baths VYLot size -------- -------------------------------- Water Supply: _______________________________Water"Supply: Public system N Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [4 Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application-Made =Yes-❑ No [X New Construction: Yes [X 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 wel -____ . Distance from foun ation____________________Material__. No. of compartments...0-------------------Size--------l --__ .Liquid depth-_---_S� __._Capacity_____11{_____.``,,� Disposal Field: Distance from nearest well 1vXistance from foundation_ /f._.....Distance to nearest lot line__14_ 1..__ i Number of lines--------- __ ---__- Length of each line____j#p} _ __.�._ ,--_- .-.Width of trench--- - -- Type of filter material" ----- �.-� Depth of filter material.-..0?-/__- Total length__-._-1?-1� 1._-��---14- Seepage Pit:' Distance to nearest well �iN—V_Disfance from found n___.ta Distance to nearest lot i e_ a �' ° �r p � [ Number of pits____j.�-----------Lining materially-__Size: Diameter.__._ __2__ _________De tn_:- 1 ' `___..________ Cesspool: Distance from nearest well----------------- from foundation-...___.___._.___.Lining material_._..__________.__�___..___________ y ❑ Size: Diameter. ---------------- Depth --------------- •-------------- ------Liquid Capacity------------------------...gals, ' _______ --- from nearest building-. u_ _ __._________- Privy: Distance from nearest well ._ _ --_-_-- g--------------� - ❑ Distance to nearest lot line....._--�-_f Remodelingand/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) - �a v .yam- ---- `Z----- _�0.rer..and/or,Contrac+or}T BY: !� i� -: I11is- -!-. ----------- -------------------------------- (Ti+le)- - --------------------------- (Plot plan, showing size of lot, location of system. in relation to wells, buildings, etc., can be placed on reverse side). FOR DEP TMENT USE ONLY APPLICATION ACCEPTED BY--- ------------------------ DATE_ ----------------------•---- REVIEWED BY------------------------------------ -�--------------- ------------------------------------- ------ DATE----------•------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------- -------------------------------------------------•-• •---•--._ DATE------------------------------- ----- Alterationsand/or recommendations------------------------------ _ ------------------------•-------------------------------------------•-•---------------------------------------------------- -----------------------------------•--------------------------------- ----------------------------------------------- ---------------I---------------- ......---........ ------------------------------------------- -------------------------------------------------------- ----------------------------------------------------------•--- -------- ----------- ------------------------------------------------- ------------------- ----------------------------------------------------------------- ; FINAL INSPECTION BY:.. Date --------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E S-9 14s445 ATWOOD