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APPLICATION FOR SANITATION PERMIT Permit No. ..... 1 /1 `] � u • { �(Complete in Duplicate) . �} !�V p P 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. Sy (" �I ". =,-F2la y /V �'JOB ADDRESS AND LOCATION - ---- J --- �_. -_. ` - ---- Owner's Name....--------_ --------------- E _.._- �---------- ---------------------- ------- ----------- Phone--- Address - Address---------------------------- •----------------------S ---- ��-,----------------------------------•--- ------------------- Contractor's Name-------------- ----------•--------------------------- f '------- - Phone--------------------- ------ Installation will serve: ResidenceX Apartment House ❑ Commercial'❑ Trailer Court ❑ Mot I ❑ Other ❑ Number of living units: -------- Number of bedrooms _"Number of baths I-___ Lot size ---------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table .------- ft. Characfer of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay.Loam ❑ Clay ❑ Adobe,-P Hardpan ❑ Previous Application Made: Yes E4 No ❑ New Construction: Yes ❑ No Q. � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T90Distance from nearest wall--,--------------Distance from foundation_.________________Material-___._______.__.______.___.___________________ ' No. of compartments---- - ------------------Size------•-------------------------Liquid depth-------------------------Capacity----------------------- Disposal eld: Distance from nearest well-_ - _._Distance from founc4ativf__.. .�K-------Distance to nearest lot line-------��__. Number of lines_____------- ----- --- ---------Length of each line_......I�O___'_:_____.Width of trench._-.-_- ----_Z 'f_- �y! ------- Type of filter materia -----Depth of filter material__.._.f�d-.-___...__.Total length___________________ ------....... JSeepage Pit: Distance to nearest well----------------------Distance from foundation-.------------------Distance to nearest lot line------._.---_____ ❑ Number of pits________________ ____Lining ma1 terial---------------------..Size: Diameter-----------.__..-.-..-Depth__..________.___ 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----------------------------------------------------------------------------------------••-------------------------------------------------- r Remodelingand/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 rules and regulations of the San Joaquin Local Health District. -------- -----------•------ ----------------------- --- ---------------------------------------------•----•- --- ----- Owner and/or Contractor (Signed]______ _ _. { / gY ----- --------- -------- -----------------------------------------(Title)-------------------------------------------------------------- (Plot plan s wing size o lot, location of system in anon to wells, buildings, etc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- -- ----- - - -- --------------------------------------------------•- ------ DATE------------ / --``--- --- -- ------------------------ REVIEWEDBY----------------------------------------------- -- --------------------------------------------------------------------- DATE---------------- -------- - -------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----- -------------------- ------------------------------- Alterationsand/or recommendations:------- ------- -----__-------- ------------ -------------------•-------------------•-------•------------------------••----------------------------•- ---------------------------------------------------•-------••--------- -------------------------------------------------------------------------------•-----------------------•--------------------------------------- -----------------------• -----------------------------•------------------------------ ------ ---------------------------------------------- -------------------------------------------------•----•-----•-----.------ -----------------------•--------------------------------- -------------------------------------- ---------------------------------------------------------------------------------------- - -------------------------------- 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 Y~ E5-9-2M 145446 ATWOOD 12-54 II