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APPLICATION FOR ,—,ANITATION PERMIT'- Permit No. .--- (Complete in Duplicate) j Data Issued ��s"'-�- Applica�ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. his application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION..___!5_� __---- -_____ - - r-�3 '---------- ------------------------------------------- - - ----------- Owner's Name .¢ ° ----------------------- ------�a�3 A •C t 1 n -- ------------------ ------------------------- Phone.- Address- hone.Address. i�# A.! ---------- Contractor's Name ( -----•---------------------------- - ----------------------------------------------- ------------ Phone-. -•- --- -- •- `(--•- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Othgr ❑ Number of livingunits: __ Z..- --__ Number of bedrooms ______ Number of baths ____j__ Lot size _/--�,G___-____�!_ ------------------------------ Water __________________________ Water Supply: Public system N�Community system ❑ Private ❑ Depth to Water Table4�-�___ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe P--Hardpan ❑ Previous Application Made: Yes [❑ No Lam' 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 well-_:______._. Distance from foundation___________________Material ❑ No. of compartments --------- ---------------Size--------- ----------------------Liquid depth--------- - --------------Capacity.--------------------- Disposal Field: Distance from nearest well--------------- Distance from foundation____...............Distance to nearest lot line.______-.--______ ❑ Number of lines-------------- ------Length of each line------------------------------Widfh of french-_--------------------------------- Type of filter material___ -----------------Depth of filter material____-_-----------------Total length------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line--___._.__-__-___ ❑ Number of pits----------------------Lining material----:------------------Size: Diameter_--------------------Depth-- ------------------------------ .�esspool l ptf►Gw Distance from nearest well_----- V.,__Distance from fo�yrdatian. ----- Lining material--..__k -___------_-_---. ------ Size: Diameter ` "-�------------------- Depth 2"5 ---- ------------------Liquid Capacity_._lotQ-'tl-------..._gals. Privy: Distance from nearest well------ -- ----------- ------------------------------Distance from nearest building-----------------------------------------. ❑ Distance to nearest lot line-----------------------------•-- ._.:. Remodeling and/or repairing (describe):- - -•- A -- - °`^ ''---•-• - ------ ------ -------------------------------------- -----------•----•----------•----•------•------------------------•-------------•-•-------------------------- ---------•-----------------------•-------------------------•----••-------••------------------- '------------------------------------ ---------------------•------------•---------------------------------------------•---•---- ------------------------� I hereby certify that I have prepared this application and that the work will 'be done in accordance with San Joaquin County ordinan�; ate laws, and rules and regulations of the San Joaquin Local Health District. (Signed).. __ _ (Owner and/or Contractor) ----Za----------------------------------------------------------------- Y - - - -- ------------ •-------------------------------�------------------------- - -------------•----------- (Plot plan; showing siz of lot, location of system in relation to wells, buildings, etc., can be placed on reverse FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --- ---------------- ------- •----------------------fDATE----------U ---------------------------- REVIEWED BY - ;+,DATE BUILDINGPERMIT ISSUED------------------------------- ------- -- ---------------------------------------- ------------- DATE------------- ----------- ----------------------------------- Alterafions and/or recommendations:_-_____------------- ..-•-------------•-----•--•----•------------- -------------•------•----- ---------------------------------------------------------------------------.__....---------_.-----------•----•-- -------!/-------•----------- -------•---•--------------------------------------------------- ---------------------------------- -------- -------------------------------=-------- ---------------•-------------- -----••--------------- •-------------- -------------------------------- FINAL INSPECTION BY:- --------- Date__ _ {J - v SAN OAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9 145446 ATWOOD f