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'-��✓ k1) APPLICATION FOR SANITATION PERMIT Permit h. .._ .. V (Complete in Duplicate) s 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 Ordinance No. 5499,. / ,( JOB ADDRESS AND LOCATION 11 `�" ---- ---------- !�-j1 Owner's Name Phone --------------------- Addressff' '.. -- -- --------------------------------------•-------•--------------••-•----••---- --------•--------•--•-----•--•---•-------•-•- Contractor's Name-----_�- -- ----•• ---- - ---•-- Phone Installation will serve: Residence PfApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _f----_ Number of bedrooms __1�7. Number of baths //___ Lot size ...... -_�` �— Water Supply: Public system g_Community system ❑ Private ❑ Depth to Water Table �c ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2�—Hardpan ❑ Previous Application Made: Yes ❑ Noj/5�-New Construction: Yes ❑ Nd__R_ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: = kance from nearest well__,____________Distance from foundation--------------------Material_______-_---____-___-_____________-_____-_____- ❑ o. o ompartments----------_-------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: -Dis ce from nearest well_________________Distance from foundation-----------------._-Distance to nearest lot line................. ❑ lines---------_----------- -----------Length of each line----------------------- ------Width of trench..•-------------------------------- Type filter material________________________Depth of filter material---.........-----------Total length_____________________________-____________ Seepage Pit: Distance to nearest well-__Mow-te- ),stance frog foundation__ �40__....Distance to nearest lot line...... Number of pits----/-------------Lining materiaDiameter__�_„�_�lbepth----- ------^.___ 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------------------------------------------ (AJ ❑ Distance to nearest lot line------------------------•---------------- ---------•-----------•----•-•-----------•-------_----•--------------------------------------- g an9 (describe): Remodelin d ________--_ /or repairing Pirin -----------------------------•--....-._..---•-•--------------------•----•-------•---- -------•-----•----•------•--------------•-----------•-•-----------_-_--------•---•-••-----------•--------•------••---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County v ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. 1.. -____Owner and/or Contractor ) --- --- -----------------------------� - -- ---- ---- ------ ---------------------------------------- (Signed)...... Title-��---------- ---- --- -By:. (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.....4`................................................ REVIEWEDBY--------------------------------------------- --- ------ DATE-------------' BUILDINGPERMIT ISSUED---------------------------------- - --------------•-------------------•-•••-•-••--------••----.._.._ DATE------------------ - Alterations and/or recommendations:___________________ ____ '"] ------------------- ------------------------- r�` {� ,f'', r----------------------------------------------------------------------------------------------------------------- --------------------------- -----------•--- - s.-------------------- -------------- ------------------- --------• --------_-- -------- ---------------•------------ ---------------- 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 145446 ATWOOD