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APPLICATION FOR SANITATION PERMIT Permit No. _ (Complete in Duplicate) 1 � Date Issued Applica4-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 Ordinanc No. 549, JOB ADDRESS AID LOCA ---- Owner's Name------ ----------------------------------------------:--------•----------------- -- ------------- Address...-----------_ ------------Address______________ -ert- - ------------------------------------------ Phone_14.__.4_.7 7V ---•----- --- ------------- -----------------------------------•----------•----------•----------- - --�-� Contractor's Name...... �✓� -- - ---- - -•- ----- --------- - - -------------- Phone ------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court C] Motel `/❑ Other ❑ Number of living units: _1---- umber of bedrooms Number.of,baths _�-.___ Lot size -_`�_O__ h •� { - - -- Water Supply: Public system Community system`❑ Private F1- Depth to Water Table ___. ft. = Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe�ardpan E] 1 Previous Application Made: Yes ❑ No New Construction: Yes ( /No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet # Septic Tank: Distance from nearest welL71V_'- ,-__Distan e f m f Ida'ion_f®_______- •---. e.t ,aI---- .� 4 ®� Flo. of compartments,- 'yx'_______----Size-.___� --' _1�1Liquid depth.. -- Y------ ...--.Ca acit P. Y Disposal Ilield, Distance from nearest well______ _________Distance from foundation------------- Number of lines----------------- --------------- --____.Distance to nearest line-------.---------- 4 ❑ -Length of each line------------- -------- t lo .---.._.Wid#h of trench --t to----------------------------------- Type or filter material_____________________ _Depth of filter material__.__--_-- -----------------------Total length------------------ --------•---- -- Seepage t: riDistance'to nearest well --------Distance from foundation _. Distance to nearest lot line_--S_-___•--_-_ . Number of its___- -'- p Lining ma#ertal_l1f9r,� --------Size: Dia eter__. .�. -------Depth_.. _f- ------ Cesspool:-�r Distance from nearest well-----------------Distance from foundation-------------------- material__._.._- ----.- ----- + {� Size: Diameter Depth-------------- ---------------------- -------------Liquid Capacity---------------------• -----gals. r'rivy: Distance from nearest well---------------------------_-+_-_---------.__---Distance from nearest building----------------------------- E� Distance to nearest lot line- '- ._ ------------ I --- ------------ ---------- Remodeling and/or repairing (describe)-------------------------------- - --tL �y - �, _-- _�t1 -------•---------------------------- ------- ---------------•------ - hereby ti - - - - •- - -'- g his 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)___.._ i_ -. -------------------------•-------- ---------------------- Title- (Owner and/or Contractor} _ ---.----- -------------------------------------- ------ ------------------ (Plot pian, showing size of I� , location of system in relation to wells, buildings, etc., can }laced on rever - P se si� FOR DEPARTMENT USE ONLY APP REVIEWED BY ACCEPTED BYq -,-n-�-- ----------------------- ---------------------------------------- DATE------ '� # REVIEWED BY ---------- ----------- W �- - --------------- ---------- --- -------------------------------------------------- - DATE BUILDING PERMIT ISSUED--- ---- ------ .DATE-------�f- a A terations and/or recommendati . __ S7------------- - ------------------------------------- -----------------------------------------------------------•-------•------------------------- ------ --- ------------------------------------------------------------------------------------------------- ---- ----••--------------- ---- J r- Dom_ Qcr � ---------------- ----------------- FINAL ---- --FINAL INSPECTION BYA,W�_ ------ - Date-.- -= 3�---s SAN JOAQUIN LOCAL HEALTH.DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "G" Street Stockton, California Lodi, California Manteca, California Tracy, California -4 Ka-9 145446 ATWOOD