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APPLICATION FOR SANITATION PERMIT Permit No. Z {Complete in Duplicate) � Date Issued .__._�_��_�� 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 //County Ordinance No. 549, JOB ADDRESS AN,DpLO/CATION.I.. (.0 �`�_ 7 �C� Owner's Name---------(f,— G: = j, Phone �� .�l__�7�f27.....--------------------------------•---------------------------------------------------------------------------- Address /- Contractor's Name----- ---- -- - -- - -----�---- C-�`�"--- ••----`•=-------------------------------------- --------------- -------- --- Phone---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:'.____ Number of bedrooms __` Number of baths F---- Lot size ------�Z Z- ------------------- ra F' f t. Water Supply: Public systemCommunity system ❑ Private ❑ Depth to Water Table-. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0�_Hardpan ❑ Previous Application Made: Yes ❑ No ®/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 weh___/1/6-?v_Distance from _., foundation---ZOf__-.._.Material--e-_p____ ---------- No. of compartments----- eepth------ /47�..0--------.-Capacity------ r -----. ------------ € ------..Distance to nearest lot Disposal Field: Distance from nearest weli-- stance from foundation_____ Number of lines____-----f Length of each line _ _ Width of french-. yrr � -:-��-- � -------• -- Type of filter material-j-A-----'ZRr..Depth of filter material....... ---- length--------.Z�-'--:jgr----------------------- Seepage Pit: Distance to nearest eIL__�d9-4--Distance,�f�roam fouQdation____-----d_--___-DistancF�o nearest lot line_-�.��--- ' Num of pits....-�---.-_.-----Lining material-6C 4 r{e: Diameter.-._ ......Depth---�—r .._.__.________ Cesspool: Distance from.nearest well-----------------Distance from foundation------------------- Lining material_-.-- ______-.-.__-._--_---.__. ❑ Size: Diameter.---------- - ----Depth------ ------•------------ -- ----------------Liquid Capacity---_--------------- ---gals. Q Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-.--_-__.._____-_--_-------_-._---_____. ❑ Distance to ne'arest 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, State I d rules and regulations of the San Joaquin Local Health District. {Signed}.. (Owner and/or Contractor) --- ------------- ---------------- --------{ (Title) ` By--- --- - --- --- ------ -- ---- " F (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--------- -------------- -- ---------------- ----------------------------------------------- DATE ---------------------------------------------- REVIEWEDBY --------------------- --------- DATE ----6------------------------------------ BUILDINGPERMIT ISSUED------------------- --------•-- -------- ----- -------------------------------------------------- DATE------------- - ----- -------------- Alterations and/or recommendations-------- --- -- ---- �.1--------------- •--------••----------•-- -•--------•-- -- � ' --------- ---- • -------------• --------------------------------------- ------------_---- ---------------•-•--------------- -- ---------- ----------------------- ----- --------- FINAL INSPECTION BY------------------ --------- ----------- - Date-----_. /�l SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E'- 9-2M 1954a6 ATWOOD 12-59