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APPLICATION FOR SANITATION PERMIT Permit No. -1-- (Complete in Duplicate) ' Date Issued ___ ell 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 No. S49. JOB ADDRESS AND LO TION_ ------------- - __ _ _____�___ _-----------------_------_----------- ......_---------_------ ___________________, -�Owner's Name-------------- =_ = ----------- Phone- ---•------1- Address----/--- --- ---- r _ -- ---- - -- ..........................•-•-- -----------•----- . ..... Contractors Name----- --- ... ----------- ---- �f---------------- ------------------ ------------------------------'-------------- Phone- - ,. -----,/.—G�+S Installation will serve: Residence Apartment House ❑ Commercial, [I- Trailer Court ❑- Motel ❑ Other ❑ • II' ' Number of living units:t�___ Number of bedrooms __ _._ Number of baths ./ e ��_- __ Lot size y ____________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tablet. ' Character of soil to a depth 'f 3 feet: '-Sand ❑ Gravel E] Sandy Loam E] Clay Loam E] Clay E] Ad Hardpan C]11 Previous Application Made: Yes ❑ No New Construction: Yes No E]" TYPE OF INSTALLATION AND SPECIFICATIONS: J \ F (No sepfic tank or ces pool permitted if,public sewer is available within 200 feet.) *. Septic nk: ` Distance from nearest well__,_________.__Distance from foundation--------_-----------Material_.____.___________.__.______________------_-___. PIP } No. of compartments---------- ---------------Size---•----------------------------Liquid dep? h--------- - --------------Capacity--------------------•-- �I ,a Disposal •eld: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- C�' Number of lines------------------------------------Length of each line-------------------------------Width of trench-----------------------.----------- %�j�/ Type of filter material_________________________Depth of filter material____._____.._______.__Total length, _ _-_______________.___.____ _-____--_-__ II $eepa e Pit: Distance to nearest well j �_�C ____Distance f, m fou nQation_��_..-..-.Distance to nearest lot line_____.__ __ - Number of pits.-_._/-------___-- Lining material- - i_Size: Diameter__________________Depth_._� __ r-_�a__ esspool: Distance'I1rom nearest well-----------------Distance from foundation_.__...._.._____._.Lining material__._....______.____.____- _-- - e: Dia❑ SizIeter------------------------- Depth ----------------Liquid Capacity----------------------------gals. Privy: I Distance From nearest well---------------------------------------------- --/co nearest building__________.__.______________._____._._. J ❑ i' Distance to nearest lot line-------- --------------------------- --------------------- -.... ' �. -__ fir + �_ Remodeling an /or repairing {descriJ�ej: Z �__� ._..--•-•-------- ----- - �5-/ ----------------------------------------�' ----------------------•----------------------------------------------------- •�'� v All I- ------------------------- �. ------------------------- ----------------- ..---=--------------------�-------------------- ............. -••------••---•---•------------------------------------------------------- - I hereby , rtify that I have pre ared this a olifion and that the work will be done in accordance with San Joaquin County ordinances, State and rules nd r ulations%of the San Joaquin Local Health District. (Signed}---------- -------- ---- ------i- � - ---- -- ------------------------------------------ ---------------------------------------- - wrier and Contractor) BY= , ---------------------------------- (rifle} ��-�'' "'-`--*- . (Plot plan, showing size of lot�h-locatio system in relation fa wells, buildings, etc., can be plape on r v se side}. 4. - " I FOR DEPARTMENT USE ONLY v APPLICATION ACCEPTED-BY. - f`x -- - ------ DATE---------f— ----------- ----------------------------- REVIEWED BY._ '`== -11 DATE------- ----------X ---------------------------- ---- • . BUILDING PERMIT ISSUED---------------------------- -- ---- DATE------ --------- - --------- ----------------------------------------------- ------ ----- - Alterations and/or recommendations:-- -------- { --------------- -----------��------•-•-------- V y-� '�� 1 -` ciy--q ----------- = r r� /------------- ' FINAL INSPECTION BY:.-� ____s----------------- ------ Date.--..I.------------------ --- - 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 145446 ATWOOD 12.54