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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) w ,. Date Issued .-W/.__��_ 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 Qedinance No. 549. JOB ADDRESS A D LOCATION ----•---• -- -- Owner's Name---- ---------- -------- ------ �� - Phone --------- -- - ------- ----- --- e C� C + Address === ----------------------- Contractor's Name---- ------------------------------• -- -I--- ---------------------------------- Phone----•-----_---------------------- Installation - --------- Installation will serve: Residence 510 Apartment House ❑ 'Commercial ❑ Trailer Court ❑] fM�ote] E] Other Otthyer ❑ Number of living units: __ -- Number of bedrooms __Z_ Number of baths .-1-____ Lot size ___ __`7`_ -j-_ !�:-_�_________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam [3,, Clay Loam E] Clay ❑ Adobe -Hardpan L]Previous Application Made: Yes E] No New Construction: Yes MOONo ❑ - TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permittedrif public sewer is available within 200 feet 0141 Septic yank: Distance from nearest well__ . ,istan�`e,from fo nidation_ _._..._.___.Mate�rJ'SII_________________________ ----_______ No. of compartments_.____.._ ____ ._t_Size_.�_.+. _ X_ ___.__Liquid depth---------- __ _____ ___ _ Disposal`Field: Distance from nearest well____....'_Distance from foundation �� .Distance to nearest lot fine—_ s� Number of lines__________ _ _ _ __ t___ Length'of each line----- �_"_..� -- Width of trench_.._. ___- J.gType of filter materia°l. _ .o ____ _ pth of filter mater aL...___ __..___Total length------------ __ ____________.._ Seepage Pit: Distance to nearest well_---------------ZrDisfance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining rmaterial----------------------.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----------------- ------ ---------------- - -...-.----------------- --------•------------------------------------------------------ Remodeling and/or repairing (describe):____________________ a i ---------------------------------------•--•------••-----------------------------------------------------------: •---•----•---------------------------•-•------------------------ --------------------------------------- -------------------------------------------------------•--•------------•--•------------------------------------------------------------------------------------------------------------------------ I ------------------------------------ ---------•-----•--------------•-------------------------------------I—...........1--------------------------------------------------------------------------------------------------- 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 laws, and rules and red ulations of A n Joaquin Local Health District. j 4(Signed) --------------- By: �. " ----- -------- ------ ------------------------(Owner and/or Contractor) t4 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 ---------i---------------------------------------------------- DAT .e-`_-_---------------------------------------------------- REVIEWED BY-------------------------- = _ =--------'- DATE-- - BUILDING PERMIT ISSUED--------- ------------- ----------------------- -•---------------------------------------- DATE.. Alterations and/or recommendations:------- -------------------------- ---------- - ----------------------------------------------------------�-•--------------•---------------. ----.-------- -•-----•------------------------------ ---------------------• -------------------------=--- -----------------------•-----------------------------------------------•-------------------•--------------------.------------------ -------------------------------------------------- ----------------•---- ----------- -----------------------------------------------------.-------------------------------------- ------------------------------------ FINAL INSPECTION BY:. -------------- ---- ------------------ --- ----•- --- Date.... -1--------------�------------------------------------------------ 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 rS-9-2M 145a 6 ATWOOD 12-54 i%