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\ APPLICATION FOR SANITATION PERMIT Permit No. ...... __. "'I �-'O (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 County Ordinance No. 549. JOB ADDRESS AND L ATIO -.....�:�/..35_----- , Owner's Name- -- --------- ------------------ Phone------------------------------------ ------------------------------------ - ---------------------------------------------------------------------------------------------------- --------------------------------------------- Contractor's Name----------------!/`'' ------------------------------------------------ Phone Installation -------------------------- Installation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __l_. Number of bedrooms -.I... Number of baths _/__ Lot size -----la ------------------ Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table/70"Wft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe n-"Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No F'r' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan Distance from nearest well_________________Distance from foundation--------------------Material .,._._..__._..-___..-_.--_______.____..._______ E �� No. of compartments------------------- -----Size-------------------------------Liquid depth-------------------------Capacity---•------------------- e Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line---------- �� Number of lines----------------- -----------------Lengthof each line------- ---------------_Width of trench Type of filter material-----------.-------------Depth of filter material------------------- ...Total length-------------------------------_---_._... Seepage Pit: Distance to nearest well____ -Distance from fou ation__--/&--------- Di ance�to nearest lot line_��______ [� Number of pits------- Lining material....a n-A' Size: Diameter_..-.,,, „' p ' Depth - -r------------ ]U Cesspool: Distance from nearest well.................Distance from foundation---------------.___.Lining material-----.------------------------------- ❑ Size: Diameter. - Depth ---------------------Liquid Capacity------------------------ gals. C� Privy: Distance from nearest well..---------------------------------.----. `V .__..___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 laws, and rul s and regulations of the San Joaquin Local Health District. (Signed)---------------------- - - (0vr Contractor) Bn, showing -- y` - (Title)------ - - --- - ------------------ - --------- r''��------------- (Plot plan, showing size of I location of system in relation to wells, buildings, etc., can be placed on reverse si )• FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------_----- ....._._._ DATE_...... REVIEWED BY • ----------------- ��--- DATE BUILDING PERMIT ISSUED `z -------------- DATE.- ----------- -� Alterations and/or recommendations: ....... -1 • ------------------------------ ---- - - _- -.�----------•-------- FINAL INSPECTION 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