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APPLICATION FOR SANITATION MIT Permit No. -------- R _ • ,, (Co ! in Duplicated �,�`' j y/ Q, !! �"� Date Issued ---------I9 Applica�ion is hereby made to the San Joaquin Local Health District for a per 't to construct a install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AID LOCATION---- ---------- QiIL --------- -------------- Owner's Name --------------------------- -------------------------------------------------- -------------- ------------ -- Phone_ -- d-k -Z j70g Address_ _.__ ___ - - + . Contractor's Name_________________•-_--_- ' - ---- - ----- ------ Phone_ Installation will serve: Residence -- ---��-�`��"-- �Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units. __/--- Number of bedrooms -_`3__ Number of baths __�_-- Lot size __ ------------- d!/ '�" Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table S�_ ft. Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe B----Hardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes H--"qo [] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest waif - ----------Distance from foundation_- � +� Sd' Material-- ------ ---- /1.c No. of compartments ---------------- ------------- ---•--- p rzZ.-� ----- ----Size_SG�'�r'--------�---Liquid depth-----`--0--- --- • Capac�ty._l, pQ-. Disposal Field: Distance from nearest 5 -�-_ Distance from foundation.-__/�-�_-.--Distance to nearest lot line-_'S�__---•-• Number of lines--------�-----------------------Length of each line / O'------------Width of trench_ y-N---_--- Type of filter material.$IRA_C�-- p .� - ---------- --- ._-De Depth of filter material-____.�8'---.__--Tota! length___.�S`� _ $eepaze Pit: Distance to nearest well /0-0 t-Distance from foundation___,�_--_-- Distance to nearest lo} line-____-_.__ Number of pits--------4----___ ---Lining materiaL.?1L-4�--_----Size: Diameter-_.—" --'r A ' -------- � --------�Depth---------- g-•---�C-� � Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material___-________-..__..___- --------•---- i Size: Diameter- ------------------- �--------- --Depth--------- ---------------------- ................... Liquid Capacity---- -------gals. Privy: Distance from nearest well--------------------------- -------_Distance from nearest building ❑ Distance to nearest lot dine_________________________________ -------------------------------- --------------- ------------------ Remodeling and/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 aws, and rules and regulations of the San Joaquin Local Health District. d � {Si gne8--------- -- �_ - ------ (Owner and/or Contractor) (Plot pian, showing size of lot, location of system in r anon to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--.-. '• DATE t REVIEWED BY (� DATE \ BUILDING PERMIT ISSUED ----------------` -- ----j-------------------------------- DATE.------ - Alterations and/or recommendations:--- - --- -- - ---- ---------------------- ------- ------------------ ---------- ----------------- --------------------•----------- -------------•--------------- ---------- -- - FINAL INSPECTION BY:- - ------------- Date-.-- SAN ate-.-SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Americen Street 300 West oak Street i32 Sycamore Street Stockton, California 814 North "C Street Lodi, California Manteca, California Tracy, California ES-9 145446 ATWOOD