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APPLICATION FOR SANITATION PERMIT Permit o. -------- .&_'--- <br /> (Complete in Duplicate) / 0- 6, <br /> Date Issued ______ ____ __________ <br /> Applica}ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance <br /> / No. 549. / �/ <br /> JOB ADDRESS AND OCATION ------- • ------------W-0 - <br /> Owner's Name-------- L-------------I-et-2-e- ,5--t--.e -- --------------------------- ---------- Phone------------------------------------ <br /> Address ..._.1V o----------------`:- ./7-�--`.0 --------------------------------------------------------•----------•------------------------- <br /> Contractor's Name--------- .r ------x--------6-e-4—--nd ---------------------------------------------------------------- Phone <br /> Installation will serve: Residence X_ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: -L----Number of bedrooms __ Number of baths I----- Lot size ----.,�7?-------Ad�....................... <br /> Water Supply: Public system K_ Community system ❑ Private ❑ Depth to Water Table <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Z, Hardpan ❑ <br /> Previous Application Made. Yes ❑ No [S- New Construction: Yes ❑ No [ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: , Distance from nearest well_________________Distance from foundation--------------------Material-----------.------- -_.-.------------____._---. <br /> ❑ . of compartments----- ------- -------_--Size------------------ -------------Liquid depth-- -------- --------------Capacity----------------------- <br /> Disposal Field:` stance from nearest well. ...............Distance from foundation---_---- .__._..-.Distance to nearest lot line----------_-----. <br /> ❑ ber of lines-----------------------------------Length of each line---------------------------.-.Width of trench----------------------------------- <br /> ype of filter material--------.----------------Depth of filter material----------------------- length----------------------------------------.- <br /> Seepage Pit: Distance to nearest well-----Ye�istance from foundation-----1G........Distance`to nearest lot <br /> f <br /> line__._,? ---_ <br /> Number of pits--- ----------Linin9 materialDiameter-_---- Deptn----- ---------------- <br /> Cesspool: <br /> - - <br /> Cesspool: <br /> r, <br /> Distance from nearest well-----------------Distance from foundation--------------------Lining material.-------------.---------.--.___-_-_-. 1 <br /> ❑ Size: Diameter-- ----- --------- --- --------------Depth------------------------------ ---------------------Liquid Capacity----------------------------gals, W <br /> Privy: Distance from nearest well---------------------------------------- ------Distance from nearest building-----------------------------------------. <br /> ❑ Distance to nearest lot line-------------------------------------------- ----•------------------------•----------------------------------------------------------•-------- <br /> Remodeling and/or repairing (describe);-------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------I......I------------------------------ <br /> ----------------------------- <br /> ----------------------------------------------------------- ----- -----------------------•-------------------------------•----------••---------•-•----•-•--•-------------- ------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, St ws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) - - --- - -----------4 -------` `..- -------------------------------------------------------------(Owner and/or Contractor) <br /> By:-- L / ------------------------------(Title)---- ------------------------------------ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------------------C__ ----%-------------------------------------------------------- DATE------ _----------------------------------------- <br /> REViEWED BY --------' .-_ _<7­ 1 DATE---- <br /> BUILDING PERMIT ISSUED------------ ---------------------------- ----------------------------- DATE--- --- --CS <br /> Alterations and/or recommendations_______________________ _______ <br /> ----------------------- 04 <br /> t <br /> �! <br /> -- ------ ---- <br /> ------------------------------ ------------------------------------------------ ------ ------------------------------- -------------- ---------------------- ----------------------- ----------------------------- <br /> IFr <br /> FINAL INSPECTION BY:----- ----------------------------- Date------------------------------ -! 4_. ----- -------------------•------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-21A 145446 ATWOOD 12-sa <br />