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APPLICATION FOR SANITATION PERMIT Permit No. ------ (Complete in Duplicate) Date Issued ---- -- - gA made to the San Joaquin Local Health District for a permit to construct and install the work herein described. plica4ion is hereby This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AN LOCATION- --- ------------ --- ---------------- - ....... ll Owner's Name--.1��L-11sa-i -------- --------------------------------------------------------------------- Phone---------------------- Address---------13 ----------------------I Contractor's Name-R4-1&11!.d&_1P6k1 Installation will serve: Residence [§--Aj5-3r-tmen+ House [-I Commercial E] Trailer Court F] Motel E] Other Number of living units; ___j___ Number of bedrooms ---1,.Number of baths I----- Lot size-`,I---_X-1___2-_V______________________________ Water Supply: Public system [P—e-ommunify system-,E] Private ❑ Depth to Wafer TabI6,., ft. Character of soil to a depth �of 3 feet: Sand E] Gravel'E] Sandy Loam [] Clay Loam El Clay E] Adobe��Olclpan ❑ Previous Application Made: Yes E] No Pj--44ew Construction: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta nDistance 'lI�Irorn nearest well_ ______________Distance from foundation--------------------Material---------------------------------------------- No. of compartmenfs:--------- - - ------Size--------------------------------Liquid depth-------------------------Capacity----------------------- Disposal Field-. Distance from nearest well--- ..............Distance from foundation--------------------Distance to nearest lot line_.____-----______ 1� El Num er 61- ines-----------------------------------Length-of each line---------------------- Width of french----------__-------------- ...... T r fi Type oiter mafe6z�-------------------------Depth of filter material-.--.-----------------Total length----------------------------------------- Seepage Pit: Distance to nearest well--41-_&y%-1____Dista ncuf-6�0 .�Iaf-,on-----"/0........Distance to nearest lot line----�s---------- Number cf:pifs-------J-----------Lining materi ize: .......w------------ "Cesspool: Distance IfIrom nearest well-----------------Dist ce"fro- oundcafion....:........___...Lining material_____-...-____._____.-__.__.________.. ❑ aterial-------- ----------I----------------- E1 Dia rr efer--------- -----_De pth------------------------------ ---------------Liquid Capacity-.--------------------------gals. Privy. Distance from nearest well--- ---------------------------------------------Distance from nearest building ---- ____________.-.___-.-___-__. ❑ Distance to nearest lot line--------------------- ------- - ----------------------------------------------- or re -Re`m`od;9liFg '9�nW ` 7a ii c—iinn f, be]:____-___________________.:__ __--------------------------------------------------------------------------------------------- -------------------------------------------------- --------------7------------------------------------------------------------------------------------------------------------ ---------------------------------------------- -------------------------------------- ------------------------------------------------------------------------------------------------------------------I---------------------------- --------------I----------------- ------------------------------------------------- -----------------------------------------------------------------------------I------------ --------------------------------------------------------------------- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State Haws, and ales and regulations of the San Joaquin Local.r Haalfh DI'stricif. (Signedor 1: 41 ------------------- (Gw Contra--c-t--o--r-)- ------------------------------ -------------------------------------------------------- sY� -------------- ------- ---- ------ ----------- -- Title) --------------------------------------------- - - (Plot plan, showing size of lot)location of system in relation to w6lis, buildings, etc., can be placed on reverse side). II 3 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ------------------ ------------- -----------------------------•---------- DATE----- REVIEWED ATE-----REVIEWED BY ---------------------- -------------------- -- --------------------------------------------------------.. DATE----- ------ --- -- -------- ----------------------------- -- --------- BUILDING PERMIT ISSUED--- -------- - - ---- ------- ----- ------------------------------------------------- DATE---------- ----------- ------- ---------------------_---- Alterations and/or recommendations:------ .................\j A----- ---- ------------------------------------------------------- -------�----- --....---------------•-- ,l----------------------------------- ---------- ---------------------------------------------------------------- -------------- ------------- ---- ---------------- ---------- - -------- I , 11 ____7------- - --------------------------------:---------------------------------------------------------------------------------------------------------0. __-._- I _. --------------------U--------------------- -*----------------------------------------------------------------------------------------------- ----------------------------------------------------------------- - - ------ ----------------------------------------------------------------I-----------------------------If------------------------------- FINAL INSPECTION ---------- - - --------------------------------------------- _f r) ��4----------- ------------------- BY:... Date,2,�-—------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American afreef 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M 145446 ATWOOD 12-