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� APPLICATION FOR SANITATION PERMIT Permit No. wl� N(Complete in Duplicate) Date Issued ---- --Applicalion 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-- -•--- ----------Q. J. 7Prlr.tic� ------------- Owner's Name_----------•-- Phone Address-----•--•---•------------ � - - ---------- ---- -------------- - - i je Contractor's Name y ---•- •-------- ------ 4" - -------- --- ---._. Phon _ -•• ?� Installation will serve: Residence artmen House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _)___ Number of bedrooms ---._Number of baths ___I___ Lot size _____--- •-•---------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E iTardpan ❑ Previous Application Made: Yes ER-115-0 New Construction: Yes ❑L-Ai6❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) gi* Distance from nearesr well________________Distanceefrom foundation------------------- No. of compartments-------------------- -----Size---------------------- ---------Liquid depth--------- -------------.Capacity----------------------- Disposal F Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line-________________ Number of lines-----------------------------------Length of each line-------------------------------Width of trench------------------ ((!! Type of filter material-------------------------Depth of filter material------------.---'---_--Total length----------------------------_ Seepage Pit: Distance to nearest well....K_4'V�---Distance from foundation____" to nearest lot line _------- Dumber of pits-______I._________Lining material_ j!L__ ----Size: DiameterIfece _____________Depth-----, _ �- ______ - Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material_---_...________...____.___-_-______- I ❑ Size: Diameter------------------------------------Depth------------------------------------------- --------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well.__--------------------------------------------Distance from nearest building------------------------.________._______- ❑ Distance to nearest lot line---------------------------------- -----------------------------•-------------- V . Remodeling and/or repairing (describe):--------- -------- ------------------- -------------------------------------••------------------ -----•----------------------------------------------- ---------------------------------•---------------------------------------------------------•-----------------------------------------•-- ----------------------------------------------------%------ --------------------------- - --- - ------------------------------ ---------------------------------------------------------------------------------------------------------------------------•------•-------------------•---------------- 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 - - ---------- ------- {O and or Contractor) . By:---- = {Title) ------ u ? ----- .... (Plot plan, showing si a of lot, loc ion of system in relation to wet s, buildings, etc., can be placed on reverse side). , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ _. ----------------------------------- ------ DATES--.-------- REVIEWED BY------------------------------ %_.1 DATE : BUILDINGPERMIT ISSUED--------------------------------------- --------------------------------------------------------- DATE---- - ------------------------------- Alterations and/or recommendations----------•-------------------- ------ - ----------------------------------------------------------•-----•- - -------------------------- -------------------------------------- --- ---------------------------------------------------------- -- -----------------•-------------------------------------------------------------•-- •---------------- ----------- ---------•-------- ----------- FINAL INSPECTION B p ------------------ Date-----_------- - -- -------- -- ---------------- SAN 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 E57-9-2M 145446 ATWOOD 12-54