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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate} Date Issued --- Applicaa-ion is hereby mad,p to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------ ::_._- ---1"-�"-----��z-`------/c -- -- O -------- --- JOB ! Owner's Name-------- -- ------- ---------- • -- -_-------------------------- -- ---------------------------------------- Phone-----------------------------___---- Address----....._ ✓� �r�, -.• ------------------------------------------------------------------' •--------------------------------------------------- Contractor's Name_.h -----------••----••----------•---------------------------------------•-- --------------------•----------------- Phone----------------------------------- Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. -1------ Number of bedrooms ____ Number of baths Lot size _____'_9------ ---------------------------------- Water ________________________________ Water Supply: Public system ❑ Community system ❑ Private M Depth to Water Table .Y _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No YYl New Construction: Yes ElNox TYPE OF INSTALLATION AND SPECIFICATIONS: (No sepfic tank orQcess qol ermitted,if ublic sewer is availableTwithin 200 feet.) P_ Y P P ,....�.} Septic Tank: Distance from nearest well________________Distance from foundation-------------------Material-_-______-__-________--_______-___________-__- ❑ No. of compartments-------------------- - _Size.........-----------------------Liquid depth-------------------------Capacity----------------------- Disposal Field: Distance from nearest well:-__Y.a-__--_Distance from foundation____l_Q_----------Distance to nearest lot line.- .�-------- Number of lines,---------_1__-_-- -- Length of each line-----1�-----------------Width of trench------�K� ---------------- Type of filter material-_.__ - ___- Depth of .filter material----�. '--- -____-_Total length---- '_______________________-_ Seepage Pit: Distance to nearest well_.___.A'a---_---___Distance from. foundation----19----------Distance to nearest lot4line___s_-________ 772 Number of pits---------t------------Lining material--- ----------Size: Diameter.-_4_''t_- �------Depth------:�- ---------------------- IL Cesspool: Distance from nearest wO-----------------Distance from foundation------------------- Lining material_-___------__-___--______________. ❑ Size: Diameter------------------ ------ -----------Depth----------------------------- ------- -------- ----Liquid Capacity----------------------------gals. P-r-ivy: m=Distance from nearest well-----' _-:'--=- '----.•---Distance from Barest building=--_r_—.------------------ Distance _- :--_ ❑ Distance to nearest lot line--------------- ----------•---------- - ---------•------------•- ----•------------•--------------------- - ------------------------ -4' Remodeling and/or repairing (describe): ---A " ------ -�------ ----- ---••------------------ ---------- —---------- ---------------------—--- ------------------- ---- ---------------------------------------------.- -------------------------------- ----••--------••--------------- I herebycertifythat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and-pe ulati ns of t e San Joaquin Local Health District. = - % �- ------------------------------------------------------------(Owner and/or Contractor) (Signed)- / �. v V _ '_--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---- --------------=-------------------------- DATE----1-1_-472----------------------------------- REVIEWEDBY----- ------------------_----- ----------- ----- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------ -------•--------------------------•------------ DATE------------------------------------ ---------------------- Alterationsand/or recommendations--------------- -------------- -------------- - -----------•---------------•------------------------•-------------------•--•---•----------•--------------------- -•- •-----------------•--------•---------------- ----------•-------•- ----•-------•---------------- ---------------------------_--------------------------•------------------------- ---------------- --------------------------- - ----------------------------- ------------------------------------------------- -------------•----------------------------------•------ --------------------------------- FINAL INSPECTION BY:...,-, ......... `------ .. �-�- -------------------- Date_. -e---------------- SAN -------rSAN JOAQUIN 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