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APPLICATION FOR SANITATION PERMIT �,a ` er nit No. ..... �o._�G�S.... (Complete in Duplicated Q` 1+� v.�• 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 Ng. 549. i 7 . -------------------------------- --------------..----------------------------------------------------- JOB ADDRESS AND LOCATION___ .._-_---- Owner's Name-- vL ...... ------------------------ l' - - Phone. --------------------- . Address.....------------------------------•---------------- ----------------------- ------------------------.._-.......----•-----••----•--------------------------------------------------•- Contractor'sName _ 97�---- -_: Phone Installation will serve: Residence rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � Number of living units: - -_ Number of bedrooms w Number of bath [of size Water Supply: Publics stem 19,.Community system El Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes �o❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest -Distance from foundation--- - ------------- Mat1riaL------------------_..__--_----,._-.____-______. No. of compartments......Z. -Size___�,�-----x--�q---Liquid depth__�__.�^-------------Capacity--- - ------- Disposal Field: D.istanFe"7from nearest well,_-.2a-vu__ -Distance from-foundation___ __'-._:.::Distance to nearest lot 'fir 0-1 ,lei m`ber on lines------._-�. -- Length of each line_ --,--.-_-��--...Width of trench.--- ---------------------- •; T i? T' 11pr material---- - .------- Depth of filter material----. Total length--.-_-� a-------------- -------- J I Vw is ante to nearest well______________ --------------Distance from foundation--------------------Distance to nearest lot line----------------- U) 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 neare`st..well------ ---------------------------- ------------Distance from nearest buildi.ng-.----------------------------------- Distance to nearest lot line--- .-_.. ❑ ---------------------------------------------•----.-_•.-------------=----------------•-------------------------------------------------- i• t 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) for Contractor) 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 APPLICATION ACCEPTED BY-- DATE.... .---- -------------- -------------- ---------------------- ----- REVIEWED BY------------------------------ DATE---- - --"' '---------------------------------- BUILDING PERMIT ISSUED.------ --------------------------------- ---------------------------------- DATE----------- � -- --------------•----- Alterations and/or recommendations-------------------------------- .J 1 ---------------------•------------------------------•-------•-------------------------------------------------------------------------------------------------------------------------•--•-------------------- ------- ' -------------------------------------- ------- ------•---------------------------- ----------------------------------- ----------- ---------------------------- �. PENAL INSPECTION BY:------- - --- '-.tom- --- Date / Q / - - - SANJOAQUIN 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--9y-2M 145446 ATWOOD 12-54