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�/V h APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 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 No. 549. JOB ADDRESS AND LOCATION---Y _-------�0--_----- /fir_ _ -------------------------------- ----------------------------------------------------- ----------------------------- Owner'sName 1 e/ -----------------�+ ----- ----------------- Phone.--------------------------•--- Address...-•----- `tom ------- Contractor's Name----- � �_3/?�. - �� :-------------------- ---------------- --------------•----•------ Phone- _?&07 Installation will serve: Residence [I--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: ______-- Number of bedrooms _. ___ d , ----/ _-�-------- _ � Number of baths _______ Lot size � Water Supply: Public,system • Community system ❑ Pri vafe ❑ Depth to Water Table c-P ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑s--Hardpan ❑ Previous Application Made: Yes ❑ No [g--'Nlew Construction: Yes ❑ No [3--' .r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: /1 Distance from nearest well-----------------Distance from foundation--------------------Material ---_____...__.__.____-_ ❑.Cil(f 3t+Z1�'No. of compartments-------------------------Size--------------------------------Liquid depth------------------------ Capelcify----------------------- Disposal Field: Distance from nearest weil/i6o.M.ATDistance from foundation---s#_a_ ------Distance to nearest lot line._-2-3__�_. Number of lines---'------------ __. Length of each line_________- 0 Width of trench_..P7_�'r'0 �r 9 = - Tr----- � �;------------------- Type of filter material----/yy- _$, f:.Depth of filter material-------ZI---------Total length--------.�----------------------------- Seepage Pit: Distance to nearest well_/t/0 _ _Dista ce from foun a 'on----- Distance to nearest lot line__'?47 __ \ Number of pits----°.... _.._._.._Lining mate iaL- __� _z e: Diameter___`______ ________Depth_., ' __________________ Cesspool- Distance from nearest well------------------Distance from foundation--------------------Lining material_____.---____________________..__._. ❑ Size.Diameter------------I--------------- ----Depth------------------------------------- -------------Liquid Capacity----------------- ----------gals. Privy: Distance from nearest well_________________________ ______________________Distance from nearest building-------------_______-_.-------- ❑ Distance to nearest lof line. - ------- - ------------------------------------------------------------------- ----- Remodelin and/or re airin (describe)-_-: �� A� � L p ) ------------------- e `- ---------------------------------------------•-----------------------------------•--- H ------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------------- ------------------------- ----- --------------------------------•_•------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared +his application and that the work will be done in accordance with San Joaquin County ordinances, Stat ws, and rules and regulations of the San Joaquin Local Health District, (Signed)...... G --------- --------- ------------ -------------- ( er and/or Contractor)- -------------------------- By:.- ------------------- -------------------------------(Ti+le)-- k---------------------------------------- (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----- f REVIEWEDBY--------------------------------------------- ----- ------ ------------ - -------------------------------- DATE-----------� - -------------------------•-------------- BUILDING PERMIT ISSUED------------------------------- ---------------------- ---------------------------------• DATE----- ---- - Alterations and/or recommendation s:_ ° - -----------------------------------•------------ ------ - --- - ---- --- --- FINAL- INSPECTION BY:...._ .______ ;; ----- --------------- Dafe.3------------ -- r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amerie'an Street 300 Wes+ Oak Stree+ M : 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOD 12- 4