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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued 3 ' ------ Iry 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 ounty Ordinance No 549. / i JOSADDRESS;ANFLOCATIO .../ - /----- - -------------- -- --------------- ----------------------------------------------------------------------------- Owner's Name- ------------------------------------------------------- - ----------- -- Phone------------------------------------ ----•--- F Address _. ------- ---------_...------- ------- ---------------•-------i--------------------------------------•-------------.--- ------ ----••------ Contractor's Name-- ------------------------------------ Phone_ _. I _ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 644 Number of living units: ________ Number of bedrooms ________ Number of baths - _ Lot size __-Z_CI------------- ---------- Water Supply: Public system Community system ❑ Private ❑ -Depth to Water Table'2,55ft: Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan p Previous Application Made: Yes ❑ No Z New Construction: Yes ❑ No r I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within'200 feet.) " Sept c Tan Distance from nearest well-----------------Distance from fqundation--------------------Material.___________.__-__.___-._______________._.___-._. .i ,{ No. of compartments---------------- ---------Size:_._____ Liquid depth-----------.--------------Capacity._----_.---_--_---____ tom' s Disposal Field: Distance from nearest weld._Distance from foundation___Z�__---..--Distance to nearest lot line---d+___ ?, Number of lines---------- y__-----------Length of each line------ -&P_- t� Width of trench--_, _____---_________________ Type of filter material._.__- Depth of filter material_____----____-_Total length______ -Q------------------------- See a - --- ---- � - I rli ge Pit: Distance to nearest well__________ ______Distance from foundation_:_-__..______ Distance to nearest lot line---_---- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------------------.----------- \ Cesspool: . Distance from nearest.well-----------------Distance from foundation--------------------Lining material___-_______________-_____________-__ Size: Diameter------------------- --------------De th------------ -- ----- ------------------ ----------Liquid Capacity gals, Privy: Distance from nearest well--------------------------------------.------....Distance from nearest buildin l ❑ Distance to nearest lot line------------------- ----------------------------------------- ----------------------------------------------- ----------------- Remodelingand/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, Sta laws, and rule d regulations of the n Joaquin Local Health District. (Signed)-------- --- -- [ Contractor] - ---- ------ ------------------ - BY: ------- ...--. --- - . 1-- --------------------------------------------------------------_____-------(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_ --------------------------------------------------------------------------- - DATI�..�---------------------------------- ---------------- 1 REVIEWEDBY----------------------------- -------- --------------------------- --------- --------------------------------- DATEAPO--^---------•--•----------------------------------- BUILDING PERMIT ISSUED----------- ----------•-------------------------------------- DATE---- M ----- Alterationsand/or recommendations-------- --- -------------------------------- - ------------------------------------- -------____--------------------------------------- -------------••-------------------------------------------------------------- -------------- -- ------------------------------- ------------------------------------------------------------------------------------------- --- ------- - z-C1r1, Y --------------------------------------------- SAN f�x -----------•-------------- Date--------------------------- --------------------------- -- FINAL INSPECTION BY:.________________________ ___ - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 614 North "C" Street. Stockton, California Lodi, California Manteca, California Tracy, California Er-9-2M 145446 ATWOOD 12.54