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/ Permit No. y� �{ APPLICATION FOR SANITATION PERMIT / 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 LOCATIO ®-------- ---------------------"-----------------------•--------------•---- Owner's Name-- ------ -•ta`r'=p ---------- -- Phone------------------------------------ Address � -- ------------------ - ------------- �-�-_- � yrs { ---- Phone Contractors Name--- - ------------ -A, --• Installation will serve: Residence &_ ' Partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _4__ Number of bedrooms Number of baths I____ Lot size �___. ---------------------- 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 ---i+5`rdpan ❑ Previous Application Made: Yes ❑ No0---N-ew 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 well-----------------Distance from foundation--------------------Material_________._____._-..____---____________-___._.. No. of compartments---- -- ------ ------Size----------- --------------------Liquid depth----------------- ------Capacity----------------------- isposal Field: Distance from nearest well-------- Distance from foundation-------------------.Distance to nearest lot line----------------- Number of lines-----------------------------------Length of each line---------------------- Width of trench----------------------------------- Type of filter material--------_- """------Depth of filter material---------------------""Total length---------------•----------------•------•-- Seepage Pit: Distance to nearest well.17YW -------Distance om;oundation___/_____.___ _..Distance to nearest lot line;, Number of its------ __Linin material-_- -Size: Diameter. ----------------Deptn -- ------------------ 9 p I----- g 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--__..._______.._------------------------ r "sDistance to nearest lot line----------------- - ---------- -- ❑ ---------------------------------------- --------------- Remodeling and/or repairing (describe):--------------- - ------------------- -------------------------------------------------- --- ----•--_--------•----------- ------ -------------------------------------I---------I--- -------•---•-----------•------------•---------••------•----------------------------------------- ------------------•----------•------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, nd rules and regulations of the San Joaquin Local Health District. --------------------------------------------r ----r Contract iecaer ane_ ori -- (Title)- "�.� Confacf1vnetand_ or) plan. s owing 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---------- -- -------------------------------------------- REVIEWED BY--- ----------- ------- -- ---------- ------- -- ---- -------- -- ------------- -------------------------- DATE 1 BUILDING PERMIT ISSU DATE----------------- -------� ------------ Alterations and/or recommendations:__.__-- "-"-"- "--- ------" - ---- - --- ---••"----•-----------'" -•- P_0---------------------- -------------------- ------------------------ ------ --------------- ------- ----------------- --- --------------- -- ----------- -----"-------------------•------------------- FINAL INSPECTION BY:_"__.._.._ . "._.-- _ _ Date------- -------- ------ '----`----- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streef 300 West Oaf; Street 132 Sycamore Street 814 North "C" Street Stoek+on, California Lodi, California Manteca, California Tracy, California E9-9-2M 145446 ATWOOD 12-s4