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APPLICATION FOR SANITATION PERMIT Permit No. ....1t. <br /> (Complete in Du licate) <br /> Date Issued 41, 11 <br /> .......... <br /> AppJ <br /> lica+ion is hereby made to the San oaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance ith County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION.. . -------•----.cio-------- - -•----- ---------------------------- -------------- <br /> Owner's Name-----�__#-•- _....... �� •• --- ------------------------------------ Phone. <br /> Address--------------Q....._... �ftl�Y✓re..' ---•------......................................................... ----------•---•----•-l------ <br /> Contractor's Name--- ---- .- --------------------•--- <br /> Installation will serve: Residence i16 Apartmmt House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ...!_ Number of bedrooms/__- Number of baths .f___-_ Lot size _/,�._ ___________________________ <br /> Water Supply: Public system ❑ Community system ❑ Private 14-0epth to Water Table 3ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ar pan ❑ <br /> Previous Application Made: Yes ❑ No 6—New Construction: Yes ❑ No <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_!o---_.__Distance from foundation----- r.......Matyri l___ _ _ <br /> No. of compartments----- Size..�G---Y.-LI(�------Liquid depth_ y_____________Capacity----91j_-9_..__. <br /> Disposal Field: Distance from nearest well�d------.Distance from foundation_._.AS..._.. <br /> Distance to nearest lot line._/_0._ ...W <br /> Number of lines_..-----/------ Length of each line______ Width of french----�2_y_-�'.................. V1 <br /> Type of filter material-_�__.`.r-------------Depth of filter material---....��_______.Total length___.--i.-_ <br /> 4_0-------------------------- � <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----_............ <br /> ❑ Number of pits______________________Lining material-----------------------Size: Diameter..................-----Depth.-.-_-.-_.-.--.---___--.-,__.... Y <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material__----__---.---_-_-__--____________--. <br /> ❑ Size: Diameter-------------------------- -----------Depth-------•-------- -------------------- -- --------Liquid Capacity............................gals. <br /> Privy: Distance from nearest well-------------._-----------_---------------------Distance from nearest building------------------------------------------ <br /> ElDistance to nearest lot line---------------------- -•------------------------------------------------------••-------------------------------------------------------._.. <br /> Remodelingand/or repairing (describe):----------------------------------------------------••-------••-------------•-••••--....--•-•••--•••----•-----••-••----•••••---•--•-••-••---••......•-• <br /> ---._....--•----••-----•--------------••----•--------••------••-••--•--------------------•-•----•..............•••••--•------------------------------••-•---------•-------•--•------•---•--•--------•-- -------------. <br /> ---••---------------••---•-••••------------•--•----••--•-•••------•-•-•-•----•-•••-•-•-----------•--•••-----•-••------••-•-•--•••-•------••••-•-••-•-•-••---••---......-------•-•-----•••---••---........................... <br /> ------------•---•--•---------------•--.....----------•••--••-•-•-------•---••-•----•--•-•-•--•-•---------•---------•-•---•••--•---------------•--•--•---•------ ----------•----------------- -----•------------•--- --------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinancesWsize <br /> to laws and rules 8 d regulati ns of the San Joaquin Local Health District. <br /> z..� <br /> (Signed).... (r1�o Contractor) <br /> By: -. - - --- - -----------=---------------------------------•--..........------•---.(Title) ----- - <br /> (Plot plan, 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-------------- r Q ' .T <br /> REVIEWEDBY------------------------------------------------------------------------------- ------ DATE------------------•--------- .............................. <br /> BUILDINGPERMIT ISSUED.........................-------------------------------------------------------- ....._.._....... DATE-------------------------.-------------.-------------------.- <br /> Alterationsand/or recommendations--------------------------- ----------------------------------------------•--------------------•--•--•----------------------------•-----•---•--•••-•-•••----•- <br /> -•-•---•------••----------••--....-----•-----------•-----------------------•-------•-----.....---------- ..----•-••-•-------------••-•---_---•------......-•------•---••-•---•---••------••--•..........••--...............•-- <br /> --------------------------------------------------------................I---------------­........................................................................----------•--•-•-----•----•--•........................... <br /> ------------------------------------ ------------------- ---------------------------------------------------------------------•------------.-.-----------------..-_--------------------------------------------------------- <br /> --•-------------------------------- ---__----------- -----...-•------------•--. .................... ...................... -----------------------------------------------------------• •---------------- ------ <br /> FINAL INSPECTION BY:.----- Aft-4......... ----------- 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-9-2M 145446 ATWOOD 12-54 <br />