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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) Date Issued J/?4--C---- 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. -__- .. - - - --•------- ------------------JOS ADDRESS AND CATI ----__-- J-I- _- _--- _ Phone Owner's Name... Address--•--•-------- -------------------------------------- ------•--------------------•------------ Contractor's Name--------DA,...... -- - - -- ---- --- -------------------------------------------- Phone-W44_'9ke-7--- Installation will serve: Residence a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _- -_-_ Number of bedrooms _.!;?-7 Number of baths ----I_ Lot size ------- --------------------------- Water Supply: Public system V�,Community system ❑ Private ❑ Depth to Water Table 1'-d-- ft. Character of soil to a depth of 3 feet:' Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[& Hardpan ❑ Previous Application Made. Yes ❑ No �g_ New Construction: Yes ❑ No"[&_ : TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: D•stance from nearest well-----------------Distance from foundation-------------------Material-..---------.--.-_.-------_.-._-----.-----------. ❑ of compartments-------------------- - ---Size------•-`-:--•-'----- -----Liquid depth------------ --- ---------Capacity----------------------- Disposal Field: istance from nearest well------ _ ------- --Distance from foundation--------------------Distance to nearest lot line---------------- y ❑ bar of lines Length of each'line---------------------- -------Width of trench---------------------------------- T e of filter material-------------------------Depth of filter material------------------ ----Total'72R1stance .length------------------------------------------ W e ... (� -sfrom foundation_-�d.____.__.Distance to nearest lot line---- Seepage Pit: Distance to nearest well � � ` r NNumber of pits-------I------------Lining material-�.� �ize: Diameter------ - - -----Deptn___- ---...--------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------.- :.-----_-_----_-_---_-. ❑ Size: Diameter------------------ -----------'-------Depth--------------------------`- ----------------------Liquid Capacity-------------------- 9ais.� Privy: Distance from nearest well---------------------------.------=---------------Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line------------------ -- -•----------------------=--------------------------------------------------- Remodeling and/or repairing (describe):--------------------- --------------.------------------------.....-----•--------------------------------------------------------- ---------•------------------------------•--•----------•---------------------•--•-----------•------------------- --•-------•-----------•-----------•--------------------------`--------- A ---------------------•-------------------------------------------------------•------------------------------••----------------------------------------------------- -----------------•-•----------------------------------- I hereby cer#' that I have prepared this application and that the work will he done in accordance with San Joaquin County ordinances, S#ate is s; and rules and regulations of the San Joaquin Local Health District. {Signed) = ----------------(Owner and/or Contractor) --- BY: -�--- `�� :---- 5 ( tle} -------------------------------------- Ti (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 - BY-------•------------------ ----------- ------ ---------------- ---------------------------- DATE- ------ REVIEWED BUILDING PERMIT ISSUED------------------------ ------ DATE.-------------------•- -- --- ----- -------------------------------------------------------------- Alterations and/or re mmendations: �' --�� ` --- ----------•-------------------••-------....------------•-------------------------•--••-------- ------------------------V -4 --------------------------------------------------------------------------- --------------------- --------------------------------------------- i FINAL INSPECTION BY:..---- ----------------• -------•------- Date------ --�---� ------------------- SAN ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American.Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i ES-9--21A 145446 ATWOOD 12-54