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APPLICATION FOR SANITATION PERMIT Permit No. ._ �_ _.... (Complete in Duplicate) / Date issued ___ !f�_�.__ 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 with County Ordinance N - 549. JOB ADDRESS AND LOCATIO -----r- -- - ----- ---- ---- --------------------------------------------------------------- Owner's Name---•- � s----t.�.- -•-••------ ---- -- ------------- Phone------------------------------------ Address..... ..................... --•--------------------- -••--•------- Contractor's Name---- ---- -- __- •- -----------------------------• -------•----------------------------------------------- Phone--------------------------------- Installation will serve: Residence WApartment House ❑ Commercial ❑ Trailer Court ❑ ivotel ❑ Other ❑ Number of living units: .`----- Number of bedrooms _ _.._ Number of baths _1____ Lot size ____1�U_.0-_.__)C------L6__'C3----------- Water Supply. Public systenK Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AciobtW�Hardpan ❑ Previous Application Made. Yes ❑ Ncl New Construction: Yes ❑ No 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__n0#__1d)istance from foundation-----�I -------- .Material__ ._ __ZS.!-1_A--_ No. of compartments-..-- ___Size___---___Liquid depth--__-T---------------Capacity._ Disposal Field: Distance from nearest welI)VQJy_-Z Distance from foundation._-!_O_..._._..Distance to nearest lot line------ Number of lines----------- --------I---------- gth each line---.-- _-- -- -`__--._.Width of trench-- -r ------------- Type of filter material-S--e- -- -�_ alter material____ _ Total len th_____-_-- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line_-____.._________ ❑ Number of pits----------------------Lining material-----------------------Size- Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--_--- --------------------------__.. ❑ Size: Diameter--------------------------------------Depth----------------------------- --- - ---------- -----Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----------------------------------.-------------Distance from nearest building____-_.--_____..________-_____-__._____._. ❑ Distance to nearest lot line------------------------------------ - Z Remodeling and/or repairing (describe):-- 4r"e" :. ----- ------------ -- --------- -------•----------------------------- ---••-------•--------•------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed] r sem` N h'f�. Zr ----------------- -------------------------------------------------i------------- ------.(Owner and/or 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-- ---------- ----------------'-- ------------------------------------------------------------- DATE------->--------------- ----------------------------- REVIEWEDBY-------------------------------------------------------- ---- -------------------------------------------------- DATE--- - --------- ---•-------------------------------- BUILDINGPERMIT ISSUED-------------------------------- -------- -------------------------------------------------------- DATE----- ------ --------- .------- --------------------- Alterations and/or recommendations:- - �- --------------------•--------•-----------•-------------- ------------------ a -------------------------------------------------------------- ................ ------------------- ---•-------------------------------------------------------------------------•-------------------------------- F1NAL INSPECTION 13Y:_ .. Date----- ---)------- --------------F- ------ --------------------•-------- 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 ES-9-2M 14Sn46 ATWOOD 12-5a