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A bb �► APPLICATION FOR SANITATION PERMIT Permit No. ............... A (Complete in Duplicate) } (o _ Date Issued .............l/_.: 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_. .:/P� ._.. _ .___. ,r"Q _%.O Ff �!'o X•-• r1:'re Owner's Name---- .4�------��- 7------------------------•----------------------------------------------------------------------------- Phonel74>Y� ------- Address.........h_-%3f O 6��t l N----------------------------•-------------------------------------. ��'IF'ItSS/5� 1 e----------------------------------------------------------------------- � e_lp��„T----- Contractor's Name_____________________ __ Phone_... .__ Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ........ Number of bedrooms .Z Number of baths __I__ Lot size ---/ � ..........-------------------------------------- Water Supply: Public system ❑ Community system ❑ Private �epth to Water Tabled!?�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[3-115rdpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No 23 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------------------------------------------------- ❑Z',r&S 1W7 No. of compartments--------------------------Size_---------------------------.Liquid depth--------------------------Capacity----------------------- Disposal Field •/ y Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑,01yt. l' Number of lines-----------------------------------Length of each line----------------_-------------Width of trench-._.--_-___---_______.___---____-__ Type of filter material-------------- ---------Depth of filter material.----------------------Total length.......................................... Seepag it: Distance to nearest well.-/.6ro---_-_Distance om foundation_,,^d.�.___.Distance to nearest lot line._�d_/... i- — U' Number of pits--------/.___.__.._-Lining mate ria l_ _l_C K._.Size: Diameter-l" -------------Depth.._..r'�_3_.................... Cesspool: Distance from nearest well----------------- from foundation--------------------Lining material_._-_---_--_--_-__________________. ❑ Size: Diameter--------------------------------------Depth--........................----------------- --------Liquid Capacity----------------------------gals. Privy: Distance from nearest well ...------------------------------------------___Distance from nearest building-------------............................. ❑ Distance to nearest lot line-------------------------- ------------------------------------------------•-•----•------•--------•---••------------------------------- Remodeling and/or repairing (describe):__ ' _______________........................................................ ----------------------------------------------------------•----------------------------------•----•------------------------------------------------------------------------•---------------------•-••-------------.--------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. �/Q!Sl,� !S/C' ----- Ow and/or Contractor (Signed) ------------------------ ) By —--- -- -------- - (Ti+le) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be place on re rse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---- ---- ------- - --- ------ ------------------------------------------- ----- DATE------ . --............----------------------------...... REVIEWEDBY----------------------------------- DATE..............;;;` ......................................... BUILDING PERMIT ISSUED - DATE- - -------`-_-_- Alterations and/or recommendations _--- --- - ----------------------------------------------------- •.--. ....... -------------------- ._------ --- �... -- ---•- ---...... ( ••------------• ............................................ ... ........k----7----................_.._•----- -------------------- ----- -- -.-��--��------------ ---------------------------.._.. ---------------•------••---•---•------------••- --------------------- ---------- ---------------------------------------------- FINALINSPECTION BY:.......... --------------- ------------- Date------- ------.----------------------------------------------------------------- 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-9-2M 145446 ATWOOD 12-54