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APPLICATION FOR SANITATION PERMIT Permit No. -----2- j� 3 (Complete in Duplicate) {f Date Issued .___. __�'9�,5-� �So-� i�' Applica+ion is hereby made to the San J aquin Local Health District for a permit to constructF.,nstal t e or erein dAscribed. This application is made in compliance nth Coun Ordinance o. 549. �-7.�-7r�/ Aj. C L-(til S� S / : Is JOB ttDDRESS AN L C ION ' ° ----.�''�----- � U - - Owner's N - "--- ---••--- --------- ----•-----------. -------- ---------------- Address - Phone �C�-- Address------- ---------- ------ ----------�--:.--- --------------�4-��- -- ------•-� •- ....------------------------------------ Contractor's Name. ' --------�--'-- --- ------------ Installation `-------�� '�`�•� Phone-- I hone , A Installation will serve: Residence [ Apartment House ❑ Commercial E] Trailer Court E] Motel E] Other ❑ Number of living units: ---- /Number of bedrooms __umber of baths ----/ Lot size _.'r__.___ F Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table,30ft. vt- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam lay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ❑ TYP INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic Distance from nearest well__ ______________Distance from foundation-------------------Material-----------------___-----___________.___________- No. of compartments----- ---------------Size--------------------------------Liquid epth-------------------------.Capacity------ --------------- 1 Distance from nearest well_ ._.*Distance from foundation__ _.�i .Distance to nearest lot line____ -------- Number of lines_- ____-___ Length of each line Width of trench -- f Type of filter material__ __ Depth of filter material_ 8�!_.__.____Total length__ P------------------------------ t Seepage Pit- Distance to nearest well...*),,_-1_."____DrefiancJ fr j°u�ndation___j�_____.._..Distance to nearest lot line____ Number of pits...I----------------Lining materialL � l---Size: Diameter__„��f--------Depth.......;;L_o P Distance from nearest well_______________Distance from foundation--------------------Lining material------------------------------------- ❑ Size: Diameter--------------------------------------Depth------------------------------------------- --------Liquid Capacity----------------------------gal: h Privy: Distance from nearest well-----------------___-----------------------------Distance from nearest building ❑ Distance to nearest lot line------------------------- -- --------------- - ---------------------•- •----------------•-------------------------------------------- V) Remodeling and/or repairing (describe) --- --- --- ----------------------•----------•---•-----------•-------------------- ---•- s� -----------------------••-•----------••----------------•------ ------------------------------------•------------------------------------ -------------------------------------------•---------------------------------------- ----------------------------------------------------•------------------•----------------------------------------------------------------.--. - -------------------------------------------------------------•---------------------------------------------------------------------.--------------------------_------------------------•--------------------------------- I hereby certify that I have prepared this application and that the work will be done in acco ante with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ---• ------------ ----------- ------ or Contractor (Signed)------------------------------------------------------------------------------------------ --- - - - Title---- ----------- -------------- B (Title) (Plot plan. showing size of lot, location of system in relation to Ifs, buildings, a c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY ---- ------------------------- ---------------------------------------------------- ---. DATE�--•---•----------------------- ------------------- REVIEWEDBY------------------------------- -- - ---- --------------------------------------------------------------------- DATE--.)&--.------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE.. --n------------------------------------------------ Alterationsand/or recommendations-----------------------------------------------------------------------------------------------•-••-----• 5 �-------_--_-.----•-•------------------------- ----------------------------------- ------------ -------------•--•-------------------------------------- ---------- :••-----------------------•--------------•-----------------------------------------------------••- ---------------•----------•-•--------------------------------------- ------- -----------------------------------------------------------------•----------------------------•--------------------------•-------- FINAL INSPECTION � Date....f-3D b . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Streef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 5-9-2M 145446 ATWOOD IZ-54 A