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APPLICATION FOR SANITATION PERMIT Permit No. -----2.1.2(...... `C. (Complete in Duplicate) g So 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.witthCounty Ordinance No. 549. JOB ADDRESS A L C TION--__._7 -- ----- - (`�---��►5-------------•-•----••------•-----------------•-•------------ .._.. Phone------------------------------------ Owner's Name----4 - -- -- - -- -----•--_----- -------------- -------------------------------- Address ------------- ---------------- Address-------------_---------- -------- ---------------------------------------------------------------- ......... ------------------------ ---------- -----=--------------- --- � Phone` -------------------- Installation 2� .Contractor's Name.... � - ---- Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --I___ Number of bedrooms J_ Number of baths 2,._ Lot size .117-Y_fV1________________________•_ Water Supply: Public system 14--e-ommunity system ❑ 'Private ❑ Depth to Water Table ' Oft. Character of soil to a depth of 3 feet: Sand ❑ Gravel Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No 4L-New Construction: Yes 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 o74,---Distance from foundation__._ ---------Material__ .__________________ _______________ 4, No. of compartments---2-1 -----------SizitT_fG__.V_--YIJ------Liquid depth__- � -----------Capacity---OT-0------- Disposal Field: Distance from nearest wel!!J '^1__Distance from foundation..-�Q_._ _____.Dis#ante to nearest lot line__ ~_J___ [L Number of lines_______ ______ Length of each line_____ .-' -.,,-....Width of french_.. L/__"____..____________ Type of filter material----�.._�t..---_-__-_--Depth of filter material-____ ___..__._Total length_______-1,.. d-----_------------------- Seepage Pit: Distance to nearest well_e, s, -4,____Distance from foundation---3_6_r_._._.Distance to nearest lot line-j—__1 Z__ Number of pits-_-__2 __--Lining material_#&+vA__....Size: Diameter._,,, ___.___.____Depth__...R_Q__ _________________ `n Cesspool: Distance from nearest well-----------------Distance from foundation_______._-----------Lining material-_._______________.________.______. �l ❑ Size: Diameter------------------ --- --- -----------Depth--------------------- ------- ---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well____......_---------------_--------------_--------Distance from nearest building.____.________.._____________..__..______. ❑ Distance to nearest lot line-------------- ----=----%-------------- -------------------•--•------------------------------------------------------------------------- Remodeling and/or repairing (describe)---------- -------------------------------------------------- ------------------------------------------------------------------------------------------- -----------------------------------------1-----•-------•--•---------------------------------------------------------------•--------------------•----•---------------------...-------------------- •---------- -------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,},S State laws, and rules and regulations of the San Joaquin Local Health District. 4 (Signed) 1[LD' _ -(Owner-&"d74 i Contractor) By: ------------------------------------------- -----(Title)------------------------------------------------------- ----- - (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---- ----------------------- �j ---------------------------------- DATE------------- -f �'--------------------- REVIEWEDBY-------=--------------------------- --------------------------------- ------------------------------------------------------ DATE---•-----•-•----------•---------•---••---------------------- ' BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----- ------------------------------------------------------- Alterations and/or recommendations--- -----------------------�-- ----�--- ----------------------------------------------------------------------------------------------------------------------- -------------------------------- l - © ----------- �-,- .' ---------------------------------------------------------------- ------------ ------ ------ ----------- -------- -- - --------------------------------------- - --- --------------- —t-------------- FINAL INSPECTION BY:- Date - ------- -- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 145446 ATWOOD 12-54