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APPLICATION FOR �i SANITATION PERMIT Permit No. .___. L-I 0�" (Complete in Duplicate) Date Issued ---11 p lic is he 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 " r. nL Owner's Name-------------- Address----------- ----------•- Address---------•• y��l•��---•- --r� --�---�-- -`5.-------.---�••----------- ---- --- j�-�- -T- -•-�----l--�-----. - C--�_-'.- . ------- hone -•----------•---- - - - -�_��---- n ----------•---------••------ ontractor's Name------ ------------------------------------------------------------------------------- -- ------ Phone----------Installation will serve: Residence ❑ Apartment House ❑ Commercial railer Court ❑ ,My Motel El Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -_.---- Lot size Pl--i/- -,'�.�'� Wafer Supply. Public system [) Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gr vel ❑ Sandy Loam ay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_.,,&-rA4%9istance from foundation-`v. No. of compartments...... -- p 2 Size l(, __x =--_Liquid depth---�-- - Capacity ^- Disposal Field: Distance from nearest well-� -„_f."'Distance from foundation- .Distance to nearest lot G e--- Number of dines----��-- -------- --Length of each line----_. french-.- y ~--- g �'d---00--��.----.-.Width of --at7400---------------------- Seepage _ ___ ____ Type. of filter material__-A.h��Depth of filter material....J_�_----------Total length-_.---_ Seepage Pit: Distance to nearest well_---__---------------Distance from foundation------------ r_ I Distance to nearest lo} line----------------- ❑ Number of Pits----------------------Lining material--•--- ----------------Size: Diameter.----------- ---------Depth--- ----------------------- esspool: Distance from nearest well-----------------Dis}ance from foundation-------__---.-.--__ Lining material-----_----- ___.._-----____-__ ❑ Size: Diameter------------------ -------------------Depth--------------- Priv ----------------------Liquid Capacity---------------------------gals. y� Distance from rom nearest well------------------------- _--._---Distance from nearest building -------------------- ----- ❑ Distance to nearest let 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)-- ---- --------------------- ------------ ------------------------------------------------- -------(Owner and/or Contractor) --- ----------(Title)------ --------------------------- ---------------------- (Plot pian, s owing size o I t, location'of-ys#m in relation to wells, buildings, etc., can be placed on reverse side). ART EPr5E O Y . APPLICATION ACCEPTED BY . ----- - ATE-- , REVIEWEDBY------------------------------- --- ---•--------------- ----- ------------------------------------- ------------------------------------------------- DATE----- - �------•----------•-- ----------------------------- -BUILDING PERMIT ISSUED------------ --------------------- ---------------------------------------------------- Alterations and/or recommendations----------- --.... `...... ... ------------ -------------------•--------------- FINAL INSPECTION BY:..------- .' . L..,. Date------- - /5.7� i = 3 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California LS'-4-2M 145446 ATWOOD 12-5a