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i APPLICATION FOR SANITATION PERMIT Permit No. .................... (Complete in Duplicate) Date Issued ___________ Applicaa-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-—- ----------- -(o-Q ------ --4_�- -- -- :.C- :.- �G Owner's Name----------------C�4 �-E ---•--•--- ��- ----•---------•----------------------- ------ -------------- Address------...4 zl.Q---- --------------------------------------------------- ----------••---------------•----••-•-•---------------------------------------------- Contractor's Name____.____ __' ._� {1-G -[ ____-__-._. Phone_;44__ 'Z d_1 Installation will serve: Residence 7 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _J____ Number of bedrooms j�2_ Number of baths J____ Lot size ;X/4 d__-____________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table-5-v ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeo Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ NoV1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r 40pp.ic Tank: Distance from nearest well-- __------_Distance from foundation________________ Material____-_-_-._._______.-______--_.______-__..___.._. No. of compartments- - ---------- ----------Size------•---------------------•--•Liquid depth-------------- - --------Capacity----------------------- Field: Distance from nearest well_------___.-._._Distance from foundation--------------------Distance to nearest lot line______________--- ,y,.y Number of lines----------------------------------Length of-each line-----_-----.------------------Width of french------.------------_--------------- ( Type of filter material-------------------------Depth of filter material----_------------------Total length-_-_________________-__-_______________.._ Seepage Pit: Distance to nearest well.�cp&___Distance from fo ndation___a.4Q�.___.Disfance to nearest lot line Number of pits----- Lining materiae'_•_-__Size: Diameter____�?r ______..___.Depth__ ___ __ __ 1._� {Q 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)---------------------- --------------------------•-•--•-•------------------------------------------------------------------------ --------------------------------------------- -----------------------------------------------------------------------•-----------•-•--------------------------------------------------------------------------------------- ----------------------------------------------•-------•------------------------------ ---•-------------------•-------------------------------•-----------------------------------•------------ ------------------------------ 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)....- -- _ --�-------_- - ----- -------- . .---............... --------------- - ------- caner and/or Contractor) ---� •-.. By: --------------------- • '.'e�----------�-------'- ------------- ----------------------------(Title _ --- - - ---- ------- - ---------------------- (Plot plan, showing size of lot, location of syste relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY--------- --- ------ ------------------ - - ---------------------------•------------- DATE----------- REVIEWEDBY-------------------------------------------- ----------------------------- -------------------------------------------------- DATE----------- --------_---------------------------------- BUILDINGPERMIT ISSUED------------------------------- ---------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:---------- -------------- ------------------------------------------------------ •---------------------------------------------•------------------------------ ------------------•--------------- - -�.--------- - --- -'''--- -------•----------------- -----------------------------•------------------------------------- - ---------_--------------�. f------------------------------------------.------------_.----------------------------------------------------.-------------_-------------._.----------_----------- ......... ---------------------------I---------------- - ____________________________________________________________________________________________________________________________________________________ FINAL INSPECTION BY:----- 1 --------------------------- Date---- ------y----------- -------------------------------------------------- SAN -------`----------------------------------SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West CA Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E!3-9-2m 145446 ATWOOD 12-54