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"� <br /> ,p( APPLICATION FOR SANITATION PERMIT Permit No!..�S..�(...... <br /> l -L ' (Complete in Duplicate) <br /> Date Issued <br /> ApAI <br /> plica+ion is hereby made to the San 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 o. 549. <br /> JOB ADDRESS A D LO ATION..... ......0�1r�l <br /> . S'�a ---------- --- _---•---------- ----- -- -------•------------------------------------------•-----------•------------ <br /> Owner's Name------ . -••••.. . ..............lGGZ/!LO --- ._ Phone- --------------------------- --------- <br /> Address------------•---- -----���g...S,...�Contractor's Name (01100-t-4 -------------------------------------------------------------- -------------•-- Phone..... <br /> Installation will serve: Residence"` Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: j---- Number of bedrooms a_. Number of baths ._I_._. Lot size -----7.57-XIS-0.......................... <br /> Water Supply: Public system ❑ Community system ❑ PrivateX Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobes`^s-,ardpan ❑ <br /> Previous Application Made: Yes ❑ N019 New Construction: Yes o El / �� _ <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 /> ❑ No. of compartments--------- ----------------Size--------------------------------Liquid depth---------------- ---------Capacity-------_-------------- <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 material-..---_---------_---.--Depth of filter material----------------------- length.......................................... <br /> Seepage Pit: Distance to nearest well-.----_--------------Distance from foundation....................Distance to nearest lot lino................ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---____--__-----------------------Depth-------------------------- <br /> - -----. -_ __-- - <br /> Cesspool: Distance from nearest well...`^��_0--._.-Distance from//foundation----1Q ---.Lining material----- <br /> Size: Diameter--------- _. -----------Depth---_._--_---(�- ---------------- ---- ---Liquid Capacity gals <br /> Privy: Distance from nearest well .------.----------------------------------Distance from nearest building-_--------------------------------------- <br /> El <br /> -_-_-_ ---___--- __-__--- <br /> ❑ Distance to nearest lot line-------------------------- -------------------------------------------------------------------------------------- ------ <br /> Remodeling and/or repairing (describe)--------------- - ------------- --------•---•--•---•-•-------------------------------------------••----------•----•••---•- 3.................. <br /> ------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------ <br /> -------•----•--••-----•----- --•-• -•---- --•-•---••---•----•-------•---------------•--•-----------------•-••--•---•-•---------•-•-•--•---------------------. ------------------------------------------------------------- <br /> I hereb certify that I have prepared this application and that the work will be done in accordance w4h San Joaquin County <br /> ordinance , tate ws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) f... . - (Owner and/or Contractor) <br /> B ---------------------------------------------------- ---------------------------------------------(Title)-----------------•------------------------------------------- -. <br /> (Plot plan s owing size of lot, location 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 /> ---------------- , /U , <br /> REVIEWED BY----------------- --------- �=fv-- � , s t�. ........... DATE------------ <br /> .. .. ........----------- <br /> BUILDING PERMIT ISSUED.............. ...... ------------ f - .................................... DATE...................... ---- <br /> ----------------- <br /> Alterationsand/or recommendations:....................................................................................................................------------------..............------••-- <br /> -------------------------------------------------------------------------------------------•------•----------------------------•------------------••--•------••---•----------•------•----•-•----•-••----•-•---...--•----•--_.. <br /> ---------------------------------------------------•----.- ----------- ------ ----------------.-.-......---------------------------------------------------------•-•--------------------------------------•-------- <br /> ----------------------•--.- - --.r-------------------------------------------------- <br /> �f q <br /> FINAL INSPECTION BY:------ ----- -----------------------------------------•---- Date--------_�_�._ /� .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 /> ES-9 145446 ATWOOD <br />