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101 APPLICATION FOR SANITATION PERMIT Permit No. _kb4--_/ (Complete in Duplicate) 0�% Date Issued ----- Applica4-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 No 549. JOB ADDRESS AND LOCATION-__------3) Owner's Name--- -------- 1- -- ---- ---------- Phone.--------------------- Address------- _ ------------------------------------------ -------•-------- Phone. Contractor's Name Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __,_-_- Number of bedrooms Number of baths ----- Lot size --- r-/6,� ----->�(.-...�--Q-S-------•- Water Supply: Public system J J Community system E] Private E] Depth to Water Table 4Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob edzol Hardpan ❑ Previous Application Made: Yes ❑ No ❑ 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 stance from nearest well----------_-------Distance from foundation--------------------Materia€_______-_______.__._- ❑ �f compartments---------------------- ---Size-•-----------------------------.Liquid depth------------ - --- -----Capacity_ Disposal Field: a Distance from nearest well-------------_..-Distance from foundation----------_---------Distance to nearest lot line-_____.--------_ ❑ mber of lines----------------- --------Length of each line--------------- -----_Width of trench. Typ r filter material-----------------_-------Depth of filter material---------- .________Total length------------------ Seepage Pit: Distance to nearest well- __A& istance fionn, foundation, _____-_.__.Distance to nearest lot line_ Q_/_ Number of its_.__- �l pp � Pits �------_-----Lining material-------------!�'.''�F2e�•. 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 El Distance to nearest lot line._...____________________ �- Remodeling and/or repairing (describe)_------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------•----------••---•---------------•-----------------•-•-----------------•---------•-------------------------------•----------------•-----------------------•----------------------- I hereby certify +hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, 5ta ws, and rules and regulations of the San Joaquin Local Health District. Si ned y ( g }' ---------------------------------- (0 er and/or Contractor) y - - - --- ---------- ---- 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---- --------------------- --- ---- 0 ----- -- - ------------------I------------------- --- DATE..----- -- --- ------------------------------------------- REVIEWED BY ------- - -- ------ DATE UILDING PERMIT ISSUED------••---------------- _ DATE Alterations and/or recommendations_____________________ _ ----------------- ------------------------------------------- --------------------- ------------------I--- - - ------------- --- • ----•----- •-------- - 6 ----- ----•- -- ---------------------------- -------- ------------- ( - -- ---•-------•-------- FINAL INSPECTION BY:--- --------- ---- ------------- Date.......1-_Q-•- r B � 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-V 145446 ATWOOD