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APPLICATION FOR SANITATION PERMIT Permit No. _____�Y!wS'_.. (Complete in Duplicate) 5� 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 . 549. 00000 ----- ----- - -- ------ -- �- --- --------(- ---------- ------ Owner's ADDRESS A CATION--------- � -G�- � Owner's Namee- /l'�f "-- - ---------- ----- --- • •--- ------- -------------- -------- Phone..------- I Address ..- l-.. ._ f r-- --•--•-- - /- .... Contractor's Name---- ---- -••/--------------------- --------------- ----------- -• ---------------------------•--------------•--- Phone---- { Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [-] Other E] Number ofliving units: ----*__ Number of bedrooms eZ Number of baths ---/_ Lot size ___- , _- -- -�.--____.__ Water Supply: 'Public system ] Community system [IPrivate E] Depth to Water Table 1� ft. Character of soil to a depth o 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan ❑ _- Previous Application Made: Yes ❑ NOX New Construction: Yes No L]TYPE OF INSTALLATION AND SPECIFICATIONS: '' `` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest well-...--------------Distance from foundation_-.__________.___-.Material-------------------------------------------- No. of compartments--------------------- ----Size--------------------------------Liquid depth--------- - --- -------- Capacity----------------------- Disposal d: Distance from nearest well---.-------------Distance from foundation--------------------Distance to nearest lot line.-..-_...___...-- dumber of lines-----------------------------------Length of each line-------------------------------Width of trench.---------------------------------- Type of filter material-------------------------Depth of filter material-_---_------.-------Total length------------------------------------------ Seep a Pit: Distance to nearest well-.. /`'__.Distance f m `ou ation__/�--_--_. Distacce to nearest lot,lini___7----_ V[ Number of pits----- __Lining material_ _ Size: Diameter.----.,�____---------Depth___4__C-__3___._________________ (,U -- --- -- --- Cesspool: Distance from nearest well-----------------Distance from foundation----------------- - Lining material----------------._______::__-__ ❑ Size: Diameter---------- ----- -------------------Depth---------------------------- ------- - ------------Liquid Capacity--------------------- ----gals. " Privy: Distance from nearest well----------------------------------------- ---- istance from nearest building----------------------------------_---_--- ❑ Distance to nearest lot line................ ------ ---------------------- -- ------ ------------------------------------------------------------------------------- Remodeling and/or repairing (describe): .--•--- - - ---------• -------------•------------------------------•------•---•----------------- ----•---------•------------•--------------------------------------- ------ ------------------ ----------------•--------•-----------------------------...._.._. -•---------------------- --------------------- ---------- --- ---•-----------....------- ---------------•-------------------•-•-----------•---•--------------------------------------•---•--------------------------------- -- I hereby c hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S a $ , an ule and regulations of the San Joaquin Local Health District. (Signed)-------•--- ----- -- l------•------------------------------- ------------------------------------------------------ -•----•- _--(Owner and/or Contractor] By:------------------- - - D r/:•----------------- ------------------- ------------ --------------------------------(Title)---- ------ (Plot plan, showing si of lot, location of system in relation to wells, buildings, etc., can be ced reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- DATE------------- 7----------- REVIEWED BY---------------------------------- DATE------------------ ---- ----------7------------------ ------------- - --------•-------------- BUILDINGPERMIT ISSUED------------------------- ------ -----------------------------,--....---------------------------------- DATE------------------------ ---------------------------•--- Alterations and/or recommendations:--.----.- - -------- ------------------- -- --------- •-•----------------- --------- .....p.. ------ --------------------------- -- -- ----/--•- --- --------------- -. --------------- ----- ±------ .t�^ .------ """". ''��'e'.` ----} --!f:_-:=---._r_.:_,.-A----------- --- :!n!_ - � •---_- .. ,.---� ----------- i �' _ �� r-. f;--r----- . t..+_a ._r�� -------------•------------------- ` - n. -------- r, Q/ m jj ----------------------------------- ----------------------------- ------------------------------- --- ----------------------------------------- ----------- --- INSPECTIONBY:------------------------------------------------ - ------------ 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 145446 ATWOOD 52-54 { 1