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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, J /• JOB ADDRESS AND LOCATION...-----/_-_-��---��--= - =C _t z� ............................................................. Owner's -------------------------- --------------- Phone. Address_--_------------------ --- --- Contractor's Name___- -------------------------- ------------------------------------------------ s;y�---- -- - ----- ----- Phone-- ,-� & ---------- ---- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [3 Motel ❑ Other ❑ Number of living units: _/-___ Number of bedrooms _..Y�umber of baths ./-_-_ Lot size ---�_ - ------------------------•- Water Supply: Public system [_ Community system ❑ Private ❑ Depth to Water Table eft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ .Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe M Hardpan ❑ Previous Application Made: Yes ❑ No f New Construction: Yes &No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well1 �, .Distance from foundation__IC�________- Material- �� ------------------ No. of compartments_____ Size_ `o -,, _-Liquid depth_,-J- - ..__,Capacity.__: Disposal Field: Distance from nearest well... --Distance from foundation__��_.-__--Distance to nearest lot Number of lines--------/------f__--------------Length of each line_____ ---------------.Width of trench---- V_ - - ----------- Type or filter maferial__/'__-----_5/0Depfh of filter material_..._Z...E_'_._Total length____- ' ---j_- -------------- earest lot line Seepage Pit: Distance to nearest weff_ � Distance from foupdation_____ -.__..Distance to n __l [� Number of pits------ -----------Lining maferiaLlh Diameter----- -------Depth---- -L - --f_,� -------•--- 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------ -_____._____.____.____ ._ - ---------- ❑ Distance to nearest lot Iine------------------ Remodelingand/or repairing (describe) -----r-------------------------------------------------------------------------------------•--------------------•----------- -- . --------------------- ------ .. ----------------------------------- --------•-------------------------•------------------------------------------------------------••---------------------------------------------------------------------•- -------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, artd rules and regulations of the San Joaquin Local Health District. (Sigfned)-- ; } --- --- --- -------- -------------------••--------------------------- ----------(Owner and/or Contractor) rJ Title---_-_--- `�^ By: -- --- -------- -- ------ - ----.-- -- - - - - �- --------------------------( ) � r---------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). Y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ----------- DATE--------------- REVIEWED BY ------...- - DATE-------------� --------------- - -- - Z-2 - --- - ------------- BUILDING PERMIT ISSUED---------------------------------------- - ----- ----� ----------------------------------------------- DATE------ •-- ----•------ --- Alterations and/or recommendation -__, ______________ _ �1- �!1 - •--------------------------------------•---•----------- ---------- - --------- - - ---'7-- -�---z-- -- ------- - ----------------------------------- ------------------------------------------ --------- ------- -------------------•- ---------------------------- --------------------------------- ------------------------- -----------------------------------•-------------------- - ------------------------ F1NAL INSPECTION BY:--- 5------------------------------------- Date...-----f�_.~.S--L_.--------- ---------- �---------------.._._. 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