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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 AN Ot�_ f`........... -- ION1_--- � x' 'e�rt-u - / - 20 ---------------------------------------------------------------- Owner's Nam _ _ f," � Phone , - II ©IJ --------------- Address, --'t--- !�' � •---/ ------------ ---------------------------------••--------- f Contractor's Name-------- - �f__-•---------------•--------•-------------------------------------•---------------------------- Phone_�.,! � Installation will serve: Residence Apartment House E] Commercial 0 Trailer Court [IMotel E] Other E] F` Number of living units: _ ___ umber of bedrooms _Z Number of baths ._ __ Lot size __. __ G'" Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabl,_�Q__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado�K Hardpan E]N Previous Application Made: Yes E❑ o New Construction: Ye No E]TYPE OF INSTALLATION AND SPE FICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi ank: Distance from nearest well Distance from foundation--------------------Materia#___________._..____-_____-_________.________.. c f No. of compartments------- ------------- ----Size--------------------------------Liquid depth-.------- - .............Capacity---------------------- i Disposal Feld: Distance from nearest well.................Distance from foundation-----------_........Distance to nearest lot line----------------- Number of lines-----------------------------------Length of each line------- -._---._.Width of trench----------------------------------- Z/t� Type of filfer material.........................Depth of filter material----------------------- length_.-----------_----_---.-.._.______________ l i Seepage Pit: Distance to nearest wel�_��!_ ..___Distance fbm fou dation ---------- Distance to nearest lot line f_--__-----_- Humber of its----- --------------Linin material-.-_?_' _,—__.Size: iameter___,�D..._ \n p g Depth ----------------• V] Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------------.__-__-_..__-_-----. E❑ Size: Diameter------ -------------------------------Depth---- ------- ---------------------------------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well---------------------------------------------.---Distance from nearest building.---------._-____--__------.--.._--.._. { ❑ Distance to nearest lot lire.................. -------------------------------------1XII ---------------------- ---• ----- --------- - 1 Remodeling and/or repairing (d � �J ��-•• -= "'f.� � l/ €� _ _ ._.. -------------------------- --- ------�___ ---------•----------------------••-.--------------------- - _ -L. --------------------`-----_------.---•----_----- ----------------- ------------------------ ----------------- ------------------------------------------------------------- -------•-------_----__-__-_-----_----_------_-_-__-__-__-_-----_-----_..____.------.----..---_.----.--.---..-__- / I herela certify tat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws',,ynd, ules and,r"ulations of the San Joaquin Local Health District. (Signed) - (Owner and/or Contractor) H� By: (Title)___ , 11 --------- - ------------ - --- ------------------------------------------------ -- - ------------------------- (Plot plan, showing(size of lot, location of system in relation to wells, buildings, etc., can be,lslaced n reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ---- -- - ---- --------------------- ---------------------------------------- DATE------------- , REVIEWEDBY-------------------------------------- ---------------- ---------------------------------------------.-._._ DATE �f � /- --- } BUILDING PERMIT ISSUED------------------ --------- -- ---------- -•-- --------------------------------------------------- DATE------- ------------------------------------------- Alterations ------------ -- -------- ----- --- Alterations and/or recommendations:------ -----•. • ....... ----•-----------•- ---•------•---•--------------------------------------- --------•------•----•---- 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 es--9-2M ¢45446 ATWOOD 12-54