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Permit ac' APPLICATION FOR SANITATION PERMIT '.....�._5 �. (Complete in Duplicate) Date Issued ...... 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 Coou_nnty Ordinance No. 549. 4 JOB ADDRESS AND OCATION-------- :--_------------------------------------------------------------------------- Owners Name....... ` -- .............................................................. -------------------------------------- Phone.................................... FAddress ------ -•------- ----------------•------------------•---•---------------- Contractor's Name--------•---- -- - =3-------------- :e --------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .!_-_ Number of bedrooms _*�. Number of baths _4--- Lot size _� ---- ___11?--____________________________ s Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes �❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer'ie-available within 200 feet.) Septic Tank: Distance from nearest w II_ r� istncefrom foundation.._I_e--------Material.... --_ No. of compartments-... _--._.-__-___--_--Size _ ----- __.:_..rI . �- Li uid de th____ Capacity.... . Disposal Field: Distance from nearest welli7fc,. .%Distance from foundation Z11_5_9_...-.....Distance to nearest lot line.---2.......... Number of lines-__--_/.............. Length of each line...�"d �.---.____._.Width of trench.._?�`�_______---__-_-.- Type of filter material;�-1_._ Depth of filter material__/1e_F _______Total length------ Seepage Pit: Distance to nearest weN 7�ZT Distance from,,�- f__o__un ation----��-- ---.Dist 5ce to nearest lot line__.'___�.... f, ®� Number of pits_. _:____ Lining materiaLL°_6% 5ize: Diameter_ `._.__Depth----_ .`_______________ V� 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---------------------------- -----------•----------•----......------------------•-------•--------•----••--•-- ------•----------------- 7 -a Remodeling and/or repairing (describe)-W_ —W .-••--•-•••---•-•-•-•-•••---------•--•--•---•------•--•--•--------•-- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and r gulations of the San Joaquin Local Health District. (Signed) -------fS� ---�' tr`'�` ----- ------- e+ 'Contractor} By:............................ •---•--•-------•-• --- ✓ . . •. • --.. .-•------•--• Title----- (Plot plan, showing size of lot, location system in relation to wells, buildings, etc., can be placed on reverses e FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.. -•------------------- REVIEWED BY DATE ------ DATE --------------------------------•--- BUILDINGPERMIT ISSUED----------- ------- ..... ------------------------- --•------------------------------ DATE_-----------�---..........----------- Alterations and/or recommendations------- ---------- ---- -------------------------------------------------------------------------------------- ... ------------------------------------- -•-------------------- \- ------------------ -....... --- --- -- --- ----- ---------------------•------------------------•--••---------------•• --• --------------------------------•-----•-------------------------------•------------------_._.....---------------------------------......----_ •--------- ------ FINAL INSPECTION BY:------(�..S----------- ----_- ---------- Date----- �- /-- ti SAN JOAQt11N 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-9 145446 ATWOOD