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APPLICATION FOR SANITATION PERMIT Permit No. ___41It_9__:. ' (Complete in Duplicate) Date Issued /�/ g_ 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. JOB ADDRESS AND LOCATION_.__ ---------- _________________•____ -------------------------------------------------------------------------------•------------------ Owner's Name--:�Z ....... _1� -------•--------------------- -------------------------- ----------- ----- Phone................................ Address-•--.....-=ca'� _ /-- ------------ t. e"___e.------------•-------------------...------------------------------------.._---...---------•-------------------•--- Contractor's Name -- - ----r .... - Phone Installation will serve: Residence 0—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _____ Number of bedrooms ..I--Number of baths ,/.... Lot size ....... _fr _..,; Water Supply: Public system 55L-Community system ❑ Private ❑ Depth to Water Table .......a ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeQ- Hardpan ❑ Previous Application Made: Yes ❑ No ,� New Construction: Yes„ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- f Distance from nearest well--:--------------Distance from foundation--------------------Material------------------------------------------------ ❑ i�af compartments-----_-----------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well_________________Distance from foundation.................__.Distance to nearest lot line................. ❑ Number of lines___________________________________Length of each line....----__------------____.---Width of trench_-__________________--_____________ Type of filter material-------------------------Depth of filter material-------------.---------Total length.......................................... Seepage Pit: Distance to nearest well__ Distance fr fo�und-a-t/io ."�_0_ .___.Distance to nearest lot line_�_.. Number of pits--- Linin material_. t( Diameter--- Depth-_-_-,_�_______-_-_____- Cesspool:. Distance from nearest well__________ ______Distance from foundation--------------------Lining material--------------------------------------- El _:___ _____. ___.❑ Size: Diameter--------------------------------------Depth--- ------Liquid Capacity ------_. .._.'._-•-•--_gals. { Privy: Distance from nearest well------------------------------------------------- from nearest building---------------------__________________- ❑ Distance to nearest lot line-----------------------------------------------------------•-----------------------------------------------------------•--------•--•-------- Remodeling and/or repairing (describe):-------------------------------------------------------..............................................................................I....---------------. -------------•-•--------•-•-----.__....-•--••---------------••----•-------------------------•----------•-----------------•-•---------------------------------•-----------•----•-----•-----•-----•---------- --- ------ J I hereby certify thAff I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta aws, d rules and regulations of the San Joaquin Local Health District. (Signe ---�---- ------ -- ------------------------------------------------------------.--• ..:`.(O ner and/or 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...__...__.______________.................................. REVIEWED BY------------- ---------------------_----- ;z� DATE........'`�--.............................................. BUILDINGPERMIT ISSUED-------_--------- --------- - '....------._.------••---------.-.-.-..--------.__..--------- DATE------- --- -L� -- -------------------------- Alterations and/or recommendations:__.____.._.__ __-_ --___-________________________________________________ ---- - ' 1--------------------------------- •- -- -_--------=�-------. ---�------ 0-- ._ FINAL INSPECTION BY:.--------�-�-� --,�--------------------------------- Date.-1 v= 1 "- ...4_�---------------------------------- 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 ES-9145446 ATWOOD