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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) JS Date Issued 10--_ _-- 4App�riica+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. 5491 -- JOB ADDRESS AND LOCATION.... ------- . Owner's Name_ -. ---------•--- ------------- ----------- - --- Phone------------------------•------- Address------- _:..- - - ----•------- -----•--------- --------------------------------------------' --------- Contractor's Name--. -'-►z�------- Phone/44 ----------- , .._ Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ .;— ---------------------- Number of living units: _�--_ Number of bedrooms __ Number of baths -- Lot -__ - --_-_..- Water Supply: Public system-0 Community system El Private Zj_-Bepth to LWater Table_ ft. Character of soil to a depth of 3 feet:"Sand [] Gravel ❑ Sandy Loam ❑ Clay.Loam ❑ Clay ❑ Adobe Hardpan [I Previous Application Made: Yes ❑- No �deJr Construction: Yes'[] No E�� --, TYPE OF INSTALLATION AND SPECIFICATIONS: .� (No septic tank or cesspool permitted if public sewer is available within 244 feet.) s r Se tic Tank: Distance from nearest well--,p_____________Distance from foundation-----_____-_ .___.Material___-___-_____ --_--=_._______----._-----_--_-. r No. of compartments......i-------------------Size------------------------------.Liquid depth--•- -----------------Capacity_------------------- 3-6_!__---Distance to nearest lot line-__�t... Disposal Field: Distance from nearest weli_ - -.-Distance from foundation---.-_ _ of lines----------- ..-*.-__.-.__Length of each line___- _ -."':`---=--Width of trench._.9_ -_'` ------------------- Number r Total length_- ------ ..� Type of filter materiaL_.l._ — of filter material____._. .- 00 See a �ge Pi t- Distance to est --- near .well' ----------LL------Distance from foundation---------__.--------Distance to nearest lot line----------------- Number of pits.----- --- Lining material------- ---=-----Size: Diameter-----------------------Dept h-------------------------------- Cesspool: Distance from, nearest well________________(Distance from foundation...........-------..Lining material--.--.-------------------------------- N ❑ • -Size;,Diameter-------------f----- -----`Depth------------------------------------------------------Liquid Capacity---------------------- -----gals. Priv Distance from nearest well----------------{._--"_- __-_---_-_-.------._Distance from nearest building-._-__--_-._--_-____-_-----------_-_-,_-. Y L! ❑ Distance'to nearest lot`line-" --------- _- -------- ---------------------- ------- ------------=--- / Remodeling and/or repairing..(describe) --------------------------------------------------------------•---------••------------------------------------•--•------------------------------------ ----•--------- --------------------••----- ------------------------ --------- ' ---- ---•--------------------------------------- ------ ------------------------- ---------------------- -t I hereby certify-that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Xafelaws, and rules and regulations of the San Joaquin Local Health District. ----------------•------ -- -a i-Contractor) (Signed)---- ----- -- ------ { gY= p ----------------------------------------------=--------------(Ti+ --------------------------------------------- ----------------- e (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--- --------- - ---------- - -- DATE ------ r- �Q DATE__---- ------------------------•---------- REVIEWEDBY-------------------------------- ---- ----- ----- --:----------------- ----- - BUILDING PERMIT ISSUED----------------- ------- DATE Alterations and/or recommendations---------- ------------ -----.._-_---•---•--------------------------------- ---------- y _____________________ ____ _.----------------- __ _______________________________________________ _________________________ _ ------------------------ ------------- - - ------------------/-------------- __ - --------------------------------------------------------------------------------------------------------------------- ------------ ------- _______________________________________ ____________________________________________-----_______________ _ _________ ______ _____------- Date.. ....A- --------------------- FINAL INSPECTION BY:_.-- ---- -- ------- / SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 3o0 West Oak Street 132 Sycamore Street ! 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 145446 ATWOOD i2-54