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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued --_�/AF/ Applica+ion is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordieedince w 549. —----- -- ------------- ------------------------------- JOB ADDRESS A LOCATION._.. _ . .4------- ------------ --- - --------- --- --------- -- ---- -------W-------e- - e Owner's --------------------------------- -Phon ---0-05--------- Address.............. . ....... •------------------- ---------------- ------- -- - ------------------------------------------------------- --------------------------------------------- Phone----------------------------------- Contractor's Name------9�4 - - - Installation will serve: Residence Apartment House [] Commercial [] Trailer Court E] Motel ❑ Other L] Number of living units: --- Number of bedrooms%3-, Number of baths -------- Lot size ---4)7j9----- Z�1-9 Wafer Supply: Public system ❑ Community system E] Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam E] Clay [-] Adobe M---�Mardpan E] Previous Application Made: Yes E] No C] New Construction: Yes [] No ❑ 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________________Distance from foundation__._____________---Material------------------------------------------------- F-I No, of compartments..........................Size--------------------------------Liquid depth.----- --------- --------Capacity---------------------- Disposal -------Capacity---------------------- D;sposal Field: 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----------------------Distance from om foundation--------------------Distance to nearest lot line_-__--________.__ ❑ ine----------------- R Number of pits----------------------Lining material.----------------------Size: Diameter-_---------------..----Depth...... -------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation....................Lining material__.__________.____-.___----_____,___. \\ ❑ aterial-------------------------------------- 0 Size: Diameter------------------------------------1.De p f hii,-------------------------ji---------------------Liquid Capacity-----------+------- -A----gals. Va Privy; Distance from nearest well--!5IV----- -?r----- - ----------- isfance from)nearest building-------050 --------- Distance to nearest lot line--- - ------ --- -------- -------------------------- --------------------- Remodeling and/or repairing (describe):----------------------------------- -- -- --------------------------------------------------------------------------------------------------------- ----------------I--------------------------------------------------------------------------------------------------------------------------I--------------------------------------------------------------------------------- ------------- ------------------------- -------- ........ ------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Saf� e laws,es, and rules and regulations of the San Joaquin Local Health District. (Signed)---- J -- -------- --- ------------------------------------------------------- ------------(owner and/or Contractor 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. --- ------ -------- - - ------ ------ ---------------------------------------- DATFU\--------------- ---------------------------------- REVIEWEDBY----- ---------------- - ------ ------------------- ----------------- ------------------------ DATE---- ---------------------------------------------------- BUILDING PERMIT ISSUED------------ --- ----------------------------------------------------------------------------- DATE.- Alterations and/or recommendations:_---- ----------------------------------------- -------------------------- ------------------------------tek N*---------------*------------1----------- ------------------------------------------------------------------------I---------------------------------------------------------------------------------------------- ----------------------------------------------------- ----------L--------------------------------------------- ---------------------------------------------------------------------------------------------------------------I---------------------------------------------- ---------------------------------- ----- -------------------------------- -------------------------------- -------------------------- ------------------------------------------------------------------------------- -------------------------------------------------------------------------------- - - ------- - ----------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY---------c�---- --------------- -------------- Date---- - - ------------------------------ 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 12-9.