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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) <br /> Date Issued ___NO <br /> Applica4ion is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance NO. 549 <br /> -- ---- ------------ ------------------------------------------------ <br /> JOB ADDRESS AND 0 ATION . ..... <br /> ------ --- --- - ----- <br /> ... . ....w:.�--------------------------------------------I---------------------- Phonf-- ----------------- - - <br /> Owner's Name-------- -------------- <br /> Address..........------- ---1 ------ --- -- --­-----------------------------------------------------------7--------------------------------------------------------- <br /> �7_­__ <br /> Contractor's Name--------- .... --------------------------------------- ------------------------------------------------------------ <br /> Installation will serve. Residence Apartment House E] Commercial E] Trailer Court E] Motel 0 Other [3 <br /> Number of living units: Number of bedrooms ----- Number of baths Lot size I-e I----------------------- <br /> Water Supply: Public systemACommunity system [I Private E] Depth to Water Tabl� ft. <br /> ' <br /> Character of soil to a depth of 3 feet: Sand E] Gravel F1 Sandy Loam E] Clay Loam E] Clay C] Adobe-tn Hardpan C] <br /> Previous Application Made: Yes 0 1 No New Construction: Yexs No <br /> TYPE OF INSTALLATION AND SPEC fF/I'CATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest -Distance from founda . - - <br /> n-- -------_,�ajeriaj.... ....... ­ -- <br /> ------ - -- ----------- <br /> h <br /> No. of compartments-,-,2-- ---------------- d Liquid ept .......r------------Capacity....3p>a <br /> A------ .. ....... <br /> �ion --- _5 <br /> Dis al Field: Distance from nearest Distance from foundal ion- - ----- Distance to nearest lot line_.. <br /> Number of lines______________________J�.....Length of each line______ - -49-1.......Width of trench___. I-__________--__.__.____ <br /> Type --I length__-___ -------I------------ <br /> Type T filter maferiaI__,e/-0V'_�_ - -------Depth of filter materia-------j_j. .......Total len __ 2 <br /> • Seepage Pit: Distance to nearest well... -----------------Distance from foundation------------------- Distance to nearest I& line_____.______.__.. <br /> EJ Nu.mber of pits----------------------Lining material--------------.-------"Size: Diameter.------------------_.__Depth__________----__..-------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation._.__._..._.-----_. Lining material__.._________.___.._______-_.-._____--- TO <br /> Size: Diameter----------------------------- --------Depth--------------------_-------__ ------------------Liquid Capacity_--------------------------gals. <br /> El <br /> Privy: Distance from nearest well_______________ -..____._.___..__--_.._..___._Distance.from nearest building_____________._____________-------___._._.-- <br /> 171 Distance to nearest lot line-------------------------- ---- --------- ..... .... ------ ---------------—--------------------------------------------------------- - <br /> Remodeling and/or repairing ----------------------------- -------------------••-•----•-------------------.....---• <br /> -----------------------------------------------Z-------------------------------------- -------------------- -----------------------••--------------------------------------------------------------------------------------- - <br /> --- <br /> ------------------------------------------------------------------------------------------------------ ------------------------------I------------------------------------------­------------------------------------- .. _r <br /> -1--------------- <br /> ------------------------------------ ---------------------------------------------------------------------- ­------------­------------------------------------------------------------------------------ <br /> ion- <br /> ---------- <br /> ------- -------- - - <br /> ------------- <br /> - ------------------------- ------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, S e a s, r s and regulations of the San Joaquin Local Health District. <br /> (Signed}_-------- - ----------------------- -- --------------------------------- -------------------- -- -'-.(Ow er and/or Contractor) <br /> ATIfle,----- -_ I- -------I------------------------------ <br /> By:---------------_-------�_ --------- -----------------_-------------------------------------------- ------ on ey-,2? <br /> (Plot plan, showing size'sae o lot, location of system in relation to wells, buildin,gs, etc., can be p ed on everse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B ------------------- ---------------------------------------------------------- DATE ----------------------------------------------------------------------------------- <br /> -- <br /> REVIEWEDBY--------------------- -------- ------ ------------------ DATE '_ ---------- <br /> BUILDINGDATE--. <br /> PERMIT ISSUED----------------------------------------------------------------------------------------------------- --- - ------------------------------------------------ <br /> Alterationsand/or recommendations:---------------------------------_------_-----------------------------------------------------------_--------___1--------­------------------------- <br /> ' ---------------------------------------------------- ------------------------ ----------­­-------­-­-----------­---- -----•--------------------------------------........I---------------------------------- <br /> -------------------------------------------- ------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------:m--------------- --------------1------------------ ----------------- ----------------- -------------- --------------------------------- --------------------- <br /> --------------------------------------------------------------- ------ ------------- -------- ------------------------_---------------------------------------- --------------------------------------------- <br /> ---------------- ..............------------- -------- <br /> FINAL INSPECTION BY:.------- -- ------ -——--------_------------ Date-----------5� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South ArriaFkan Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street- <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES---9-2M %45446 ATWOOD 12-54 <br />