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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in-Duplicate) <br /> Date issued ___.. 1fi_ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andinstall the work herein described. <br /> ''-;This application is made in compliance with County Ordinance'No'. 549. • 4 <br /> JOB ADDRESS AND LOCATION----_Y--(--4o--1-----A-'-�-JA_-XaA------------------------------ ------------------------------------------------------------------------ <br /> Owner's Name. tk.;r__ -- i-f _4.VrS.�!-----�. s► --------------------- --------------------- ------ ------ ------- <br /> Address-----T- _ Z <br /> Phone = = A <br /> Contractor's Name--- .� h---------------------------------------------------------------------------------- ---- •-••-•-------------•-------•----------------............ <br /> -3r__"-- <br /> w 11J;----- - <br /> _, ------------------------------------------------------------ Phone_ <br /> Installation will serve: " Residence Apar ment House ❑ Commercial ❑ Trailer Court ❑ `el ❑ Other El <br /> Number of living units: -_.1_"_" Number of bedrooms ___Number of baths __ Lot size ________-�_..-.)(_-�"�'__d________________-_-___ <br /> Water Supply: Public system Gommunity system ❑ Private ❑ Depth to Water Table -------- ft. <br /> Character of soil toga depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ .Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New.Construction: Yes fi;,-No'❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation-------------_------Material____--__-_.______.___.---___________--_-.._____- <br /> �i` 3 gAtNo. of compartments ______"_-..._---Size--------------------------------Liquid depth--------------- - --------Capacity--------------------- <br /> � _ " <br /> Disposal Field: Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line___-___-._--_____ <br /> Number of lines-----------------------------------Length of each line-------------------------------Width of trench----------------------------------- <br /> --Type-of,filter <br /> ---------------------------_--.--- <br /> --Type-of,filter material-______------___---------Depth of filter material-----------------------Total length--------------------------------."_-__-___ <br /> Seepag rt: Distance to nearest well------------_---_____<Dli ce rom ou d n__Ya............Distance to nearest lot line----/ -------- <br /> [ Number of pits------1�_______._._.__Lining i� B++_ p1biometer__.._ p- ------._De th---- <br /> Cesspool: Distance from nearest well_____________ __ an undation------------_----------Lining <br /> material_ <br /> _._-___--..__----___._____"_._----- <br /> ❑ Size: Diameter----=-------- ---------------------=--De th--------------------- - ---- ---- - ------ -- - -Li Liquid Capacity----- -------------------gals. <br /> Privy: Distance from nearest well------- _-.------------------------------------Distance from nearest building----- ---- ------------------------------- <br /> ❑ Distance to nearest lot line--- <br /> :._ r: P r <br /> ---- ------------- ----- - -------------•--- ------------ -------------------------- ----------------------- <br /> W <br /> Remodeling and/or repairing (describe)-----1+�.5,�►�_lWl IA_VUAW�I_01------ -Q.- . `_ _f _�s---+--- '- !-,!`-----L : ak_ - ­------------- <br /> •••-...-----•-----•-------------------------------------------•-------•-------------------•-------------------------------------------- ----------------•--------------------------------•-----------------------------------Z <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, State laws, and rules.and regulations of the San Joaquin Local Health District. . <br /> Si ned � <br /> ( 9 - ` -------------------------------------------------- --- -- --- - =--------(Owner and/or Contractor) <br /> Sy:---- �- = -----(Title)----------$ ------------------------------- 3 <br /> (Plot pian, showing ,Siz f lo"i..aon of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE-ONLY <br /> APPLICATION ACCEPTED BY.. ------ -----------------------•--•---------------------.--- DATE <br /> REVIEWEDBY---------------------------------------------- ----- ------------------- ---------------------•------------------ DATE--- _� <br /> BUILDING PERMIT ISSUED._--------- ------------ --- --------- -----------•---••---------------------------------------- DATE------------ ------ .- ------------------ <br /> Alterations and/or recommendations----------- ---------- - --- - --- -----..._..--- •--------------------------------------- --------- -•---��--------------••------- <br /> { - <br /> •- -- -- ------------------ ------------------------------ ----- <br /> --------------------------------------------------------------=---•-------- <br /> ------------------------------------ --------------------------------------------------- ------------ .-"....._ <br /> E � <br /> FINAL INSPECTION BY:---� .5------------------------------- -- Date___---/-.--r--__-y/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> � t <br /> ES-9-21A 1.45446 ATWOOD 12-54 I <br />