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APPLICATION FOR SANITATION PERMIT Permit No. 3.;s5._".z.o... `L 42-10 (Complete in Duplicate) Date Issued .r�___-__�.. 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. JOBADDRESS AND LOCATION --- -----•---- • • -------------------------------------------------------------------••-- Owner's Name.....�---•--. -- ... . --•-- Phone Address ---••--------------------------------------•-----------------------------•- --••-•.... --- --- -••- ��-• / Contractor's Name. ------------------------------------------------------------------------------------------ Phone .b_�� Installation will serve: Residence 01-It-partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: / _--- Number of bedrooms _-_ �,,. Number of baths -------- Lot size .....'�._Q.-----,�C......1_,�.1................... Water Supply: Public system 4-Community system ❑ , Private ❑ Depth to Water Tabler,,I'O ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No [ dew Construction: Yes ❑ No [� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SeptD'w Tan Distance from nearest well__;---------------Distance from foundation....................Material---_---____--_-___-_-_-__----------.---_-__--- No. of compartments-------------- ----Size--------_-----------------...Liquid depth-------------------------.Capacity----------------------- Dispo I Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- 0 Number of lines___________________________________Length of each line----------.__-_-_-_-_.-_-__...Width of trench................................... Type of filter material------------------------Depth of filter material-----------------------Total length.......................................... Seep ge Pit: Distance to nearest well_,ot—en-4L-----Distance from fob dation___../&.%._..Distance to nearest lot line_...--____- Number of pits------/------------Lining material...Size: Diameter_,-----t---•---Depth-.,,Y,t ------•---....--- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___-__----________--_-__.•____•__,_-. ❑ 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 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St laws and ryLes and regulations of the San Joaquin Local Health District. (Signed)-- --• ----- ----••-- ----------------- ---------------------------------------------------------- Contractor) BY� ----•- -----•-------------- -----------------------------------------------------(Title)---------------------------------------------------------------- (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-______-_. REVIEWEDBY---------------------------------------------- ----------- ----------------------------------------------------- --------- DATE-----------------------• . BUILDINGPERMIT ISSUED.............................. ---------- -------------------------------------------------------- DATE..---==-------- ---------------- - Alterations and/or recommendations---------------------- - ------------------ ----------------------------.......--------------------....-------•------. ::fid. . -------------------------------------- -------------- ----- ------ - -------- ----------•--- ••-- ----- .................... -- - • r( - ------------------------------------------------------------------------------ -••---•---------------------------- •------- ---------------------------------------------- -------------------------------------------------------------------------- ------- •------------ FINALINSPECTION BY:---- ------------------_--- Date.-. --------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814'14o h "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOD 12-54