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APPLICATION FOR SANITATION PERMIT Permi o. \� (Complete in Duplicate) Date Issued 2_ 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 OCATION........ 1----------°`5� ------/T__44- J�—_b--e—z2wt........................................................................ Owner's Name ....... ----------------------------------- ------------------------------------------- Phone.................................... Address------------------� ....... 3 ? / - Contractor's Name ... :---!&-IV-----''"T------------- -------------------------------------------- Phone................................... Installation will serve: Residence Jo Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ........ Number of bedrooms _Z-.-Number of baths _/___ Lot size ____' 1 _��C�_______________ Water Supply: Public system 0-.Community system ❑ Private ❑ Depth to Water Table _&-oft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan Previous Application Made: Yes ❑ No E--New Construction: Yes L&,_No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: D' ce from nearest well__;______________Distance from foundation....................Material___-_-______-_____-___•,_______,__-_--_____-_____- o. o ompartments--------------------- ----Size--•---••-------•--------•-------Liquid depth--------------------------Capacity-•------•-------- Disposal Field: D ante from nearest well_-........._----Distance from foundation--------------------Distance to nearest lot line................. ❑ of lines-----------------------------------Length of each line---_----------------- -----Width of trench---------___-------_--------------- �Typ f filter material-------------------------Depth of filter material----------------------- length.......................................... Seepage Pit: Distance to nearest well_/uD?-.q,_Distance from fourjdation_____cD_______.Distance to nearest lot line__...�<d1_. Number of pits__/______-_._._-Lining mate ria l__�Gfe: Diameter___-�-T_��_-Depth_____Gs��____._______ 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------------------ -------------------•-------•----•----•------------•-----------------------:----------------------------------------- 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, Sta ws, and rules and regulations of the San Joaquin Local Health District. (Signe ------� - ------------------------------------- ------(Owner and/or Contractor). vByv:- .........I--&—�-� .— �.� Cz� - -------------------(rtleD --_--- ------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------- -----------------------------------------------................_ DATE----,,„ REVIEWED BY - - ----------------------- DATE----------�-�� BUILDING PERMIT ISSUED--_---------•----------------- DATE-----------_-- -__ -� ------------•--------------------------------------- ---------------------- Alterations and/or and/or recommendations---------------- -- ----------------- --------•-----••------••-•-----------------------•----- ---- --- ��' ::-:::::::-------------::: :::: ::: :: -::::art----- ::= . - :- - --- - -----------.--.----------..----.-----.---------------------------.-------.-----.------------------------------------------------------------------------.---------:. - ._-._---•--------------- ` --------------------------------------------------------------------------------------------- --------------- 5� .:. --- -�. --• ?---9- FINAL INSPECTION BY:. Date I------------------------ 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 145446 ATWOOD 4 •.f