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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued �_Y0 05e--av—/p 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. 544, JOB AD RES AND LOCATION--- *_e_� 4 ' ------I`�y''�------ --- -------.-/p- ! - ---------------------------------------------- Owner's .. Owner's Name__--_�/_�.. 1„ lit• -r1 -- --- -- - -�1_..�_ c,/�___-------•• - -- Phone---,��_�:�.�-�-•----- Address. oJ�'• ----- '�� /-'--------------------•-•--------•-••----•---------...---•----------------------------------------------- Contractor's Name__ --___ --------------- Phone.__.--------_..__ ---------------------••--•--------•----•------...--- -•-------------------------------------------- ------------------ Installation will serve: Residence * Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --I---- Number of bedrooms .2 _. Number of baths I---- Lot size .___ ---Af%�,---------------------------- Water Supply: Public system M Community system ❑ Private ❑ Depth to Water Table _3_0_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoamZ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No Ar New Construction: Yes Z 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 well---I -_-Distance from foundation---Z-A--------Ma�rial_________________________________________________ �y+k' No. of compartments-----..2--------------Size__°_ '__ 1". --------Liquid de th--_q__4-.____.----_-.-Capacity--- Disposal Field: Distance from nearest well.-,//-!?__-----Distance from foundation----1-_Q........Distance to nearest lot line----�`11...... Number of lines---------1____ 'Length of each line--------- O ------------Width of french____-2_ __'. Type of filter material--1. Depth of filter mater�al__.� ._..___.._.Total length______pi(?-'_________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_-._-_-____--___ ❑ Number of pits----------------._--Lining material--------_--------------Size: Diameter-----------------------Depth__----.-------------------------- 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 line-- ------- ----------- ------ -------------r--------------------------------------------------------------------------------- - Remodeling and/or repairing {describe} - ---------------------------------------------------•----------•--....--------------•------------------------------------...------------- --------------•--------------------------••------------•--•----------------------------------------------------------------....-----•----•------•-------------------------_-----------------------------•-------------------- -----------••------------ ----•---------- ----•-----------------------•------------------------------------•-•--------------------------------------------------- ..-----------------------------------------------. hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County-- + ordinance ate laws, and rules and regulations of the San Joaquin Local Health District. Signe r�'G- ..� { 9 't =+ .1.•1. .... --------------------------------------{Owner and/or Contractor) By: (Title)__ (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_.--.- - - -------------40-......----------------------------------------------------------- DATE---- ' -_ -_". --------------------------------- REVIEWED - ----- REVIEWEDBY----------------------------------------------------------------------------------------------- ------------------------------ DATE---------------------- ---------------- •-------------- BUILDING PERMIT ISSUED-------------------------------- ------------------------- --------- ---------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations------------ ------ ---------- -- ------- _------- ---------- -----------------------------------------------------------•----------------------------------------------•------ ------- --------------------------------------------•-----------------------._------------------ -------------------------------------------------------•------- -------- -- ------------------------------------------------------------------------------------------------------------- - ----- ---------------•-•-------- FINAL INSPECTION BY:- J --- - ------------ Date.---�__' "f `� 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 I ES-9 145446 ATWOOD t