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APPLICATION FOR SANITATION PERMIT Permit No. .....4.7,9z— te '1 � (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-----------------5.'o 50_---- Owner's Name L-. ------------ ..p!"�CQ"Y'"------------------------- -- ----------------- ---------------------- Phone------------------------------------ Address----------------------------------------------------------------------------------------- Contractor's Name------------------------------------- ----J�J!'�-(• ----•-•------- -•------------------------------"----""---• ------ Phone.."----- ----------------- ..---••-- Installation will serve: Residence Apartment House ] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms -3--. Number of baths -------- Lot size ""_ [R" _" """I "�--------------------_ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe f" Hardpan El Previous Application Made: Yes E] No E]' New Construction: Yes E3 No E] 1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publeqsewer is available within 200 feet.) Septic Tank: Distance from nearest well----.R10-------Distance from foundation-" --------Material----------- 46✓ffQ)--- , I� No. of compartment------------- Liquid depth-------- --`�2--y- - Capacity--------- 7 Disposal Field: Distance from nearest well_._._ --------DistancefrmSyY46on-_-"�""."""".Distance to nearest lot line.----1-d"""-.-. Number of lines--------------- Length of each line-_-05--.7s'1p-.Width of trench--.------"2-VY--------------- Type or filter material----_- Z - Depth of filter material-------/�. ---------Total length---------J.fQ---------------------- Seepage Pit:. Distance tonearest well-----------------__---Distance from foundation--------------------Distance to nearest lot line----------------- R Number of pits----------------------Lining material--.--------------------Size: Diameter-----------------------Depth----------------------------.---- Cesspool: Distance from nearest well-----------------Distance from foundation.--.--------..-.-- Lining material-------------_------------------ "--. r F1Size: 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---------- ------ r•= ------------------ ..----------------•----•----------------------•-------- - = =- ----------•-----•--------------------------------------- r •-•----------------------------------- ----•----------- ------------------------------- -- ---- --- --- ..--------- .. ..----__.._."- --------------------------------------------------------------------------------------------------------------- I hereby certify that I have;prepared this application and that the work will be done in accordance with Sart Joaquin County ordinances, State ariwsrules d regulations of the San Joaquin'Local Health District. (Signed) rF - ------- ---------- ------------------------------I----------------------------------------------------------------;-----(Owner and/or Contractor) By:--------•------------------------------------------------------------- ----------------------------------------- ----------•-------(Title)-----------r----- ---------------------------------------------- (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---.------ ------------------ ------------------- 1_ - ------------------------------- DATE------ ---- REVIEWED --REVIEWED BY--------------------------- ---------------------------------------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-----------_------------------------------------------------ Aiterations and/or recommendations:---`----------------------------------------------------------------------------------------------------------------------------------------------------....... ..................................................._............•-•.............................................................................................................................................................. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------•-•------------------------ ------------------- ----------------- --------------- •-•----•--------- -- ------- ----•---•------...------------------------- ------ .......... -•-------•----- ---••--•-------------------------------------------- >" FINAL INSPECTION BY:.------ --- •---------------- Date. V.`j "' -f J i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Noah "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOD 12.54