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APPLICATION FOR SANITATION PERMIT Permit No. ..... ...�J� ... (Complete in Duplicate) 3l Date Issued ----__.._ /�_!3 Applica+ion is hereby made to the San Joaquin Local Health District for a permit to c nstruct and install the work herein described. This application is made in compliance with County Ordinance No. 5 /f JOB ADDRESS AN OCATION `'�_-- Q '' Owner's Name.- ............. ------'!'JJ1 Phone.. Address ] -- ------- -•----------------------------------------------------------•--------------------•---------------------------------------------•----------------------------- Contractor's Name �� ---------------------- ------------------------------------------------------------------------------------------ Phone.�'� -r Installation will serve: Residence rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms __Number of baths ---Z. Lot size ----e6:. -____,(...1 ________________ Water Supply: Public system 41_ Community system ❑ Private ❑ Depth to Water Table f ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No flvConstruction: Yes ❑ No Eq TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-�L_Distance from foundation_-f.-_ ---.Material--- ____________-____'-____.._..._.________._.._. 4— No. of compartments....:2-__.---------------Size__6�-C__,?C-_L1_0-•Liquid depth__-___.`- Capacity-- Disposal a acit .8Disposal Field: Distance from nearest weIlxv_v*A--_Distance from foundation.__ --.. !_Distance Distance to nearest to line.... 1 N4_1umber of nes----- Length of each line----- Width of trench_:�.�,_..'_'---------------•.- Type or filter material____1--2--------.__Depth of filter material-----f e---_-_--Total length___-3_G>__r___________________-___.._ Pit: Distance to nearest wel Seepage ls1s'l!`-i__._,Distanc om fou n.. _�....Distance to nearest tot line--- Number of pits. /----- -_Lining,materi M3 '- - ----Si a Diameter_'-f--------Depth. _ Cesspool: Distance from nearest well-__________ ____ Dist nce from foundati n-_--____----__:_-_.Lining material_-____-___-_---_____-.- -v ❑ Size: Diameter--------------------- ---------------Depth- ---------------- Liquid Capacity gals. Privy: Distance from nearest well__________________ ______________________________Distance from nearest building--------------------------------.___.____. ❑ Distance to nearest lot line--- ------------------------- Remodeling -----------------------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, �JState t laws, and rules and regulations of the San Joaquin Local Health District. _.. _---------------- -- -------------- r ------jOwner-a idf ontractor) By:--- ------ ----------------------------------------------------------------(Title)------------------------------------ --------------------------- (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 recommendations: --------------------- ........................... -------------------------- -------------------------------------------------------------- / ---- - 4 f ----- --- ----------- x -- ----------------------------------------------------- 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 L