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APPLICATION FOR SANITATION PERMIT Permit No. 10 (Complete in Duplicate) Date Issued Application 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. JOB ADDRESS AND LOCATION.......... If---------- ------ ------------- --------------------- Owner's - ------ - -------- -------- ---- Pl'ione------ ----I ----------------------- Address---------- ------------------------------------------------------------------------------------------------- Contractor's Name------ ---------------- ----------- ------ Phone - ------------------------------------------ Installation will serve: Residence Apartment House E] Commercial [ Trailer Court E] Motel E] Other E] Number of living units: _j--- Number of bedrooms ___S_ Number of baths --- Lot size ---------- -- -- ----------------------- Water Supply: Public system E] Community system E] Private q� Depth to Water Table 140%. ft. Character of soil to a depth of 3 feet: Sand 0 Gravel E] Sandy Loam E] Clay Loam El Clay El Adobe Hardpan E] Previous Application Made: Yes F1 No� New Construction: Yes A 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 weil....61'_ -___Distanc f I f d t' x--- No. m oun a ion--/.0------- --M,fe d ---------- --- No. of compartments__ ---- Size_ ; -------i 2;.,. Capacity-,- osal Field: Distance from nearest well r 6iiquid clep�th_ Disposal or Y_e�� -Distance from foundation---,e;Zl�-....Distance to nearest lot linp-S7-— Number I lines-.- -------Length of each line.____ _Akl�th of trench,-_-, Type of filter material-_5 _T, :A�.kepfh of filter k, Total length.-_-_._/ Seepage Pit: Distance to nearest well___ ------------- _,.Distance from foundation___________________ Distance to nearest lot cine...___-__-_--.._ ❑ Number of pits---------------------Lining material-----------------------Size: Diameter- - -------- ------:_Depth ------------- ---------------- Cesspool: Distance from nearest well------------- ---Distance from Distance to nearest lot line______ foundation.---_----_______ 0 Size: Diameter__.--... --- -- ------- - -- - - - ------Depth__.----------- ------------- Lining material_..-__-.___-__.-___-.... ............ Privy: Distance from nearest well. - _ ------------ ---Liquid Capacity- --------------------------gals. El -- --------------------------- -- ---------------------- ----------__Distance from nearest building------ -------_----------------- -- ---------- ------ ------------------------I------------ ------------------ ---------- ---------- --------------:------------ Remodelingand/or repairing (describe):___.__-.--- -- ----------- - --------------------------------------------- ------------- -------------------------------------------------------- --------------------------------------------- ---------------------------------------------- -------------- ---------------------------I----------------- ---------------------------------------------------- --------- ------------------------------------------------------------------------------------------------------------------I----------------------------------------------------------------------------------------- ------------- - ------------- ------------------ that I have prepared this application and that the work will be done in accordance with San Joaquin County ! hereby certify ca ---------------------------------------------- ----------------------------- ordinances, State laws, and rules and regulations of fhe San Joaquin Local Health District. I (Signed)---- --------------------- . . ............1�1_1----------- ----------- ----------- --------------- -- --- ------- -------------- ----(Owner and/or Contracforl By: --------------- --------- ------------------- ----------------- -- ---------- ---------------------- ---------- - -------------- ------ ?Vo-owing�n -------------(Tif le (Plot plan. size of IK locafi(�n of systb'rri in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- - --- ------ -- - --- ----- - -- ------- ------------------------- --- DATE REVIEWED BY ------ ............ ................ .......... - --------- ------- ............ DATE' ----------- -------------------- BUILDING PERMIT ISSUED------------ ------------- ------------------- - ------ ... DATE--- ---------------- Alterations and/or recommendations:--- --------- - -- --------------- --------------------- - ---------- ---------------- - -------- ------------- -- ------- --------------------------- ------------------ ----------------------------------I---------------------- -------------------- ----------- ------------ ------------ - --- ------------------------------- ------------ ------------------------- ---------------------------------------------------- ---------------- ----------------------- ---- ---------- -- ------- ---- --- ---------- ..... ---------------------- --- ........ __-------_-------------....... .------------ ...... - ----------------------------- ---------------- ------------ -------- -------------- .................. ----------- ------------ ------------------------ ------------------- ------- FINAL INSPECTION BY:------ ----------------_ ------------- 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 LM-9-2M 145485 ATWOOD 1y-54