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APPLICATION FOR SANITATION PERMIT PermVN ,.,..,7/ c7/ / (Complete in Duplicate) Date Issued Applica,lion,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__S 111R Owner's Name---- - '2 �- .. = -------------------------------------- - -------------------------------------- Phone " Address------------------- y Contractor's Name ---------- ---------------------------- ------•------------------------------------------------•--------- Phone -_ �h Installation will serve: Residence JAS7tment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/--- Number of bedrooms .2._ Number of baths ---/-- Lot size ----6__Q_--__�{.___._1_®-05 f ------------------ Water Supply: Public system' ommunity system ❑ Private ❑ Depth to Water Table J`12 ft. Character of soil to a depth'of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: IYes ❑ No . ew Construction: Yes eg—We ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distancelhfrom nearest well./14h�x__Distance from foundation___ A.�__.__.Material _______ -- i No. of 4 mpartments.... Size_t �__ -�(-6____-__Liquid depth_____ Ca acit -`p---__ !£-- --- p Y--- - Dis Disposal Field: Distance ifrom nearest walla- 1-A-*.__Distance from foundation_- ____ 4'` p �_...____.D�s#ante to nearest lot line___.. ____�_____ Number of lines----------- Len th of each line_____._y-,-�;-------- g 3-P-1----r -----.Width of trenc Type of filter material___- -------------Depth of filter material-___ts9--__.._Total length------Y0-------------------------- Seepage `_____________._-_Seepage Pit: Distance rto nearest weft -'-'4--__Distance from fo dation-___,_f.t__._..Distance to nearest ]of line___ y .___._-___ 1 ` -size: Diameter__. `� p p Dumber of pits-------`-------------Lining material_-- -- .7�-____...___De tn_-_ 4---------------------- Cess �ool- --Distance� -- _- �feom'tnearest well----__-.--------Distance from foundation..----------------- Lining material__--________________________________. \ ; ❑ Size: Diameter Depth T--. -- ----- quid'Capacity-`:��--�- Privy: DistanceIhrom nearest well--------------------------------------e---------Distance from nearest building----------------------A______..__,----_-_. ❑ Distance's o nearest lot line_____ _______________. _. _ f ---------------------------------------- ------------- Remodeling - ----- Remodeling and/or repairingf (describe):--------- -----------------------------------•---------••-------•--•-•--------•------- -------- r•` ------------------------------------------------- --•----------- y I - iw - --------•--- --------- ..-----•----- ----------- ----' ----------- �f y --------------•---------------------------------------------.---------------------------------------------------------_------------------- I hereby certif�-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. (Signed)---- ------ -I,- ----- ----- Piot Ian, showing size of lot, ----- ------ ----- --- -------------------------------------------- Titlep 1 Y� (Title) [ p g � location of system in relation to wells, buildings, etc., can be laced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY \ ----- -- DATE - Il M REVIEWED BY -------- ------------------- ------------------------- DATE--------------- -- PERMIT ISSUED !M - DATE - - Alterations and or recommendations--- ----------------------- _T\......... ------------•------------ - ----�2, I� f - - --- . -- '?`....----- �' ------------------- ----•-----••------- ---------- i �'� �{ --- ----- -- ---------------------------------------------�----•------------------------------------------------- --•--- ---- ----------------- ;r FfNAL INSPECTION BY:-.-' ----- -- -- � ----- --------- Date--------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" S#reef Stockton, California Lodi, California Manteca, California Tracy, California E-S-9-2M 145446 ATWOOD 1Z-54 I�