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APPLICATION FOR SANITATION PERMIT Permit No. .._!Q.......... - (Complefe in Duplicate) Date Issued AApplica4ion is hereby made to the San Joaquin Local Health District for a permit fo_oonsfruQt and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION..____ - ------- -------- 11 -------------- ---------------------------- -- wner s Name---------------------- ----- Phone----•------•------------------ Contractor's Name Name . -- ---------- Address--•----------- - --•- ��menf •------ -----f?' ... - --- Phone_ . Installation will serve: Residence House-❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units:-1----- Number of bedrooms � Number of baths __J___ Lot size ------------ E]Water Supply: Public system ❑ Community system ❑ Private ]epth to Water Table _e Character of soil to a depth of 3 feet: Sand El Gravel ❑ Sandy Loam E] Clay Loam ❑ Clay Adobe F1 Hardpan E]Previous Application Made: Yes ❑ No LNC New Construction: Yes 4-1170"0 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet. �k Distance from nearesr we} _-_-__ istance from foundati __ --___-.Material____________________________________.. - Se tic Tan.: "t"� No. of com artments--------------------------Size-------------------------_---__-Liquid depth_ -----------_Ca pacify_ P ` P Y f from nearest welL/H------_Distance from foundation.__ .(�____._-Distance to nearest lot e_ ______ p Number of lines______. __ - - ------ ength of each line---- ----- -----'------Width of trench.._._ +s osa � ------ Distance T e or filter -------- yp ter ma#eriali. c_.- ____ ----------- ,Depth of filter material__ __-_�'.-_______-Total length------------ ---------- Seepage P• :" Distance to nearest well_/ IV-----_-Distance from foudation__^7_J_ Dis nce to nearest lot line_ EYWO Number of its_-_ ------- p ��-�-.-__Lining material__ � _ _Size: Diameter__ --------Depth_____ f Cesspool• Distance from nearest well-----------_-----Distance from foundation-------------_______Lining ------------- r_1 �? ❑ Size: Diameter - -------------------Depth---------------------•------------------------------Liquid Capacity gals. \' Privy: Distance from nearest well-----------------------------_--_-_----____-__-Distance from nearest building ❑' Distance to nearest lot line--- ----------------------- ------------------------- 1: -------•------------- - �•----- ------ _ Remodeling and/or repairing (describe)______________________________ _ --------- --• -- ------ --------••---- 9--------------- - •----------------------------- , - -------=-- r" _ _ - ___ __ - ------------ ----- tf ------------ -------- -- ---- --- herebycertify that f hav �• � -------•------•-•------------------ ----------------------- I y e prepared this application and that the work will be done in accordance with San Joaquin County t ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. J (Signed)-----------••-------------- ------ .. --------------------- ------------------------------ --------------------------------------------- ----------- : ------(Owner and/or Contractor). 1. By: ------------- ----- (Title)----------------------••------------- -------------------------- I (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- REVIEWED DATE---- --•--------_ ' ----•------------•-------------- -------------------------------- R1=VlEWI=D BY _ DATE �' BUILDING PERMIT ISSUED ---- DATE Alterations and/or recommendations:---------------------- ---------------------------------------------------------------------------- -------------------------------------------------- ------ -------- ------------ ------•------- ------------ ------•------------------------ --------- ---------- - FINAL INSPECTION BY:-------=i f/ _'A�� Date f rT 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 1 -54 A .