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3 -r APPLICATION FOR SANITATION PERMIT Permit No. ..1/P- -----..._.. (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 A LOCATION.. ` ----- ---- - -------------------------------- -�..1 M / Owner's Namer� Rx -- ._- Phone-- Address---........ -- -- •-- � ---------------------- ----------------------------------•---••-•--------------------------------------------------------------------- _R/ ----------// �---------------------------------------------------------------- Phone-#&_-4 46_-_ -- .. Contractor's Name G Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:/----- Number of bedrooms . .- Number of bath - Lot size ____ � ._ Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table OV, ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan ❑ Previous Application Made: Yes ❑ No Pt New Construction: Yes X No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet �Q r Septic Tank: Distance from nearest well-_./60-_-----Distance from foundation__1�.___--____.Material_ - ______. ® No. of compartments Size___ -_ Liquid de th-_____!1`?�f._ _ .-Capacity p � ------ q {p. p Y w Disposal Field: Distance from nearest well_-j06.__ Distance from foundation____2d________-Distance to nearest lot line...%.......... Number of lines__----.--- Length of each line___-___-la_V_-_ Width of trench_..__..2 '_____________________ Type of filter material.__/ ------.$✓_-_R*_Depth of filter material-_-..d�f_____._Total length r Seepage Pit: Distance to nearest well---------------------- from foundation____.._-_-._____-_-.Distance to nearest lot line______-______-__ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------------------------------- ❑ Size: Diameter--------------------- ---- --- -------Depth------------------ ------Liquid Capacity- -------------------•------gals. Privy: Distance from nearest well----------_-----_--------------------------------Distance from nearest building----------------------------_--_.____-__-. n ❑ Distance to nearest lot line------------------------- --- ------------------------------------------------------- -------------------------------------------------- (V� Remodelingand/or repairing (describe)---------- --------------------------- -------------------------------------------------------------------------------------------------------------- 1 -------------------------•-----------------•-------------------------•------------------------------------------------------------_...------------------------•---•-------•-----------------------•--------------------------- -------------------------------- ----------------------------------------------------------------------------------------------------------------------------- ---------------------------•-------------------------- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, Stat a , and rules anc`.regulations of the San Joaquin Local Health District. (Signed)-------------- --- •------------ ---- --- ---- -------- --- --------- ----------------------------------------------------------------{ er and/or Contractor) n By:- -------------------------(Title)---- _------------------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------- ------ ---- ----------------------------- ---------------------------------------- DATE--- -------------------- -------------------------- REVIEWEDBY------------------_----- ------ -------- ------- -------------------------------------- -------------------------------- DATE BUILDING PERMIT ISSUED----•----------- ------- ------ - - DATE = Alterations and/or recommendations:____...-.--- -----------------•-----------------------------•----•------------------------------------- ------------ •--------------------•-----------------•--••--------------------------------------------------------------- ---------------------------------•----------- ------- ----------------------------- ---------------------------------••----------------------------------------------- ---------------------------------------------------- -------------------------------------------------------------------- - ------ --------------------------------- ----------------------------•-------------------------------------------.._. FINAL INSPECTION BY:--------------- 1 - Date `-�----r-.r� 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 F$-9-^2M 145446 ATWOOD 52-�4