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o APPLICATION FOR SANITATION PERMIT Permit No. ... . (Complete in Duplicate) !� Date Issued .._!.. /Xz 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 No. 549. � 6 ' JOB ADDRESS AND LOCATION ------- ----- �-� ---_-------.czv------------------------------------------------------- Owner's Name __________________ ___________________________________________. Phone--------------------------------...i_ Address............... � --•--....9��------------------ Contractor's Name----- ..... Y+--y--------------------------------------------------------------- Phone................................... Installation will serve,, Residence Rr-X'partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _j-_-_ Number of bedrooms -_..j "Number of baths ---/-. Lot size ...__ _�3___.__x� _____________________ Water Supply: Public system C�-, Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe I& Hardpan ❑ Previous Application Made: Yes ❑ No Z_ New Construction: Yes K No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__;--------------Distance om foundation__-_..._---_.-_-_--.Material-_-___----__._-___._--------_------_-.___--__---. ❑ of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity-----------_--------- Disposal Field: Distance from nearest well----/0-*sC$istance from foundation.._fq--^...__.Distance to nearest lot line----/C..f... ❑ ber of lines---------L_._____.__P-----------Length of each line.........9-..�l------width of trench...__._�l ' ..._.... ype of filter material-_-._lk-_-514—_Depth of filter material------1$_'-------Total length--------'2-„-4....................... f / Seepage Pit: Distance to nearest well__._ ! -_Dist rom foun ation. ....Distance to nearest lot lined-_...._ Number of pits------/.___...__-_Lining ma e�ial._- Size: iameter___-� -------Depth-:--40,1.'S__________________ Cesspool: Distance from nearest well-----------------D its f ion._.--___.__--___. Lining material-------------------------------------- 0 Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well---------------------------_------------------___Distance from nearest building-___----_-._________-_-----__-.--.__...... ❑ Distance to nearest lot line---------------------- ---------- ------------------------------------- -----------------------------•-------------------------------- 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 , and rules and regulations oftheSan Joaquin Local Health District. (Signe ------- - -----" ---- _ ',- ---,---------------------------------------------------------(Owner and/or Contractor) -- ---- ✓1--- ----------------------(Title)......9C�- (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_s..---r_--------------------------------------------------- Ii�REVIEWED BY-------------------------------- ---- -- ---------------------------- DATE-- -------•--•---......-------•----......-•....... BUILDING PERMIT ISSUED-------------�------------------ --------- DATE------ Alterations and/or recommendations--------------- ------- ------------------------------------------------------------------------------ ------------------------ G L - _ � lUf.� �--------------------------------- ------------------------------------------•-----------------------------....-----•--- --------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------- --------------------------------------------- FINAL INSPECTION ,BY:. -=t -- ------------------------------- Date----- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOD 12-54 i