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APPLICATION FOR SANITATION PERMIT Permit No. .............. <br /> (Complete in Duplicate) <br /> Date Issued �[. _1 _, <br /> Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> p� <br /> JOB ADDRESS AND CATION......1._P___` �f.��t'd`�C4� wc.._.C% %-�- .- -- <br /> JOB <br /> _, <br /> Owner's Name 11K• i .1........ ---- -------------------- --------------------------------------------- Phone-------------------_------- --•--•- <br /> /. --- ---------------- ---- <br /> 17 <br /> ---- _------------------------------ <br /> eAddress ---- <br /> Contractor's Name-----------------------------— ---------` --- � � <br /> Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court C] Motel ❑ Other ❑ <br /> Number of living units: _/-_-_ Number of bedrooms .°l_. Number of baths ._.l___ Lot size _Xe2__X_f ----__-________________________ <br /> Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Tabled_ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe a--Hardpan ❑ <br /> Previous Application Made: Yes ❑ No [P—New Construction: Yes ❑ No [}�' <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> p ' Tank: Distance from nearest well__;--------------Distance from foundation....................Material--------------------------------------- <br /> % .____.__.. <br /> No. of compartments--------------------------Size---•-----------•----------------Liquid depth--------------------------Capacity--------_-- <br /> isp I Field: Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line----------------- <br /> Number of lines-----------------------------------Length of each line-----------.-------------------Width of trench..-_-_,_---___.-----_.-__-_-----___ <br /> Type of filter material-------_...............Depth of filter material-.---------------------Total length.......................................... <br /> Seepage Pit: Distance to nearest well..-,74 --- -- Distancm foundation__a .........Distance to nearest lot line----S---__:- <br /> ®� Number of pits....... ------------Lining materia _---Size: Diameter.-._- Depth----- ------------------------ <br /> Cesspool: <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-----..-------------Lining material--..-._-----_-.--.-.-_-----.-__------. <br /> ❑ Size: Diameter-------- ------------------------Depth----------------------------------------------------Liquid Capacity-------_----------_-----_gals. <br /> Privy: Distance from nearest well--------------------------- ---------------------Distance from nearest building-----------------------_-_-_--.--___-_-_. <br /> ❑ Distance to nearest lot line---------- --------------------------------- --------•----•------•----- --------------_----------------------------------------------------- <br /> Remodelingand/or repairing (describe):------------------------- ----------------••••----••-----------•-----------------•-----••---•--•----------------•---•-----------------•--............... <br /> -•---•-•------•-----•---•-------------•--------••----•---------...-----------------•----•-•---•---•--•------•-•---•---•--•--------.,....--------------.....--•------••-.-------••--------•----------------- .-------•---•--- J <br /> -•--••------------------ ----------------------------------------•-------------.--------------------------------.------------------------- -----------..---•------•.--------------.--•-.-------------------.----------- <br /> ----•----------•---•------•---•----------------------•-------------•--------------------------•--•-•--•-------------•------------------•------•---.------•--------•-----•-•-----------•------•------• ------ ------ Y <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count <br /> ordinances, Sta a s, and rules Fd regu ions of the San Joaquin Local Health District. <br /> (Signed) •-•.................. -------- - (Owner and/or Contractor) <br /> By:................... • . --- •. ----• ,'� r ��--- -- ---------------------- Tale <br /> (Plot plan, showing size of lot, location of syste n relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------- -------------- ------------------------------------------- DATE---- ------------------------------•- <br /> REVIEWED BY-------------------------------------------------- <br /> -------------------------------------- -- --------------------- -------------------------------------------- DATE.-------, <br /> BUILDING PERMIT ISSUED............................ ----------- DATE. - ----------------------------------------- <br /> Alterations and/or recommendations:_ ------------------------------ <br /> --- <br /> --------- ---- ------ .-'� � ` . ------ ( .� _: <br /> ..--••----------------------- ------- ----- <br /> ---------------------------------------------------------------------------------------- ------• ---------•--- .............----------------------------------------------------------------................................ <br /> FINAL INSPECTION BY:. Date..... <br /> -7 <br /> -------------•-•--•--------------•• <br /> --------------•---=---•-----•-••----... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9 145446 ATWOOD <br />