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APPLICATION FOR SANITATION PERMIT Permit No. J {Complete in Duplicate) //-J4 9� r / � Date Issued -----_1-- ----_----- Applica+ion is hereby made to the San Joaquin Local Health Dist ricf for a permit to construct and install the work herein described This application is made in compliance with County Ordinance No, 549: . JOB ADDRESS ANWD OC ,TION_ -_ , 4 _f__. ! ------------••- Owner's Name_. - -------- -------- Owner's ------------ .---- --- - Phone------------------------ ------------------------- Address ' - ------�-- ------• --------- Contractor's Name—Name.__ ._. - ------•----•-_- - ------- ----------------------------------------------- Phone----- -----------------------------;-. --------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ �Mgotel ❑ Other ❑ Number of living units: ---1-=- Number of bedrooms __ _- -- Number of baths Lot sirf �C / �_ _ Water Supply: Public system 1 t Communit s stem 11 ---------"""" -- Character of soil to a depth of 3 feet: Sand ❑ Y Grave❑I ❑PrlSand�o Depth tClay Loamo Water able Cla ft Previous Application Made: Yes � ❑ Y ❑ Adobe LJ ►Hardpan ❑ ❑ No Lf New Construction: Yes F1 No ❑ , i TYPE OF INSTALLATION AND SPECIFICATIONS: ' F (No septic tank or cesspool permitted if public sewer is available within 200 feet) Sepfiic Tank: Distance from nearest well �� Distan afr m fou tion__/ --_--_--_.Materi I__ �i �`t.P t7�T No. of compartments-.--------.-k ` . � 9 _ Size_ �!- - _ , r .._. _ --Liquid, depth_a. - Capacity .� Disposal Field: Distance from nearest well.-- -------Distance Distance from foundation/� '�' pi5fance -fo nearesf-1,5r]i e ��' i ® Number of lines----------(' - ----------Length of each line_____ _____ __ ✓ ...__. --- f�--"_.Width of trencf�_. .�- -- . �-�? [ Type of filter.maferigI. �F/� „[DEpth of filter maferial________ _ _______Total ___.__,----- _- _ .\ length---- Seepage Pit: Distance f nearest well________________T---Distance from foundation___,-_______._____.Distance to nearest lot line_--_--__--"_--- �.. ❑ Number of its----------------------Lining material---__ --- ' p --------------Size: Diameter--------- ---------Depth---------------------- ' Cesspool: Distance from nearest well______ _______ Distance from foundation-----..__---_-- Lining material"------------------ _ ❑ Size: Diameter--=-- ------- --------------- ----=Depfih-------- �------- ------------- ILiquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------- _Distance from nearest building. -�` ❑ D15fianCE to nearest lot line__ - 9---- ----------=------------------••--"-. • ""� - •------- t ------------------------------------ Remodefing and/or repairin describe - ----- -.--" s ------------------------- --------- - ,. ------- { I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo i ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. 9 County (Signed)---•----•-- - --------------- 8Y� (Owner and/or Contractor) ----------------------------------- (Title)-------------------------------------------- _ (Plot plan, showing size of lot, location of system in relation to wells, buildings, a}c., can be placed on reverse side). _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY °_.:__ -- ._ REVIEWED BY - --------- --------------------------------------------------- DATES'- -- -- ------------------------------------------- DING PERMIT ISSUED---------- . ---- DATE--:F,'- - - _: - ----- ---------•--------------------------------------- �-- Aaerations and/or recommendations:--------------------- DATE_. -_ �- ------ -------------- ------------ --------,�-- ------ ---- , ----------- ----•----------•----- -� . --- -- �. , ---- Is— M-- ---------- . . --- - •�, ,4--------�A" A. ' . FINAL I .._. '' -•---- ------ r---- --rte � �� _. �,. INSPECTION BY:.._._....- - --p Date - --- - } iSAN JOAQUIN LO L HEALTH DISTRICT i 130 Soath American Street 300 Wes* Oak Street7 } Stockton, California f 32 Syeemore Street ' B14 North "C" Street Lodi, California Manteca, California Bracy, California ES-9 745446 ATWOOD