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APPLICATION FOR SANITATION PERMIT Permit No. —0- (Complete -0-(Complete in Duplicate) Date Issued ----___V-/s-4 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. f JOB ADDRESS AND LOCATION-•- G? J �` ------------------------------------------- -----•---•------------ Owner's Name------ ; Ir<.1 ----- _ Phone Address------ -------- ----------------------------••---•-------- -----------------------•----•-•------- f� f Phone.. Contractor s Name--------------------------------------- --------..------ ¢ i V, - �_.- Installation will serve: Residence V, Apartment House ❑ 'Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ Number of bedrooms --. Number of baths -------- Lot size .- ----------------•---------•- Water Supply: Public system ❑ Community system ❑ Private'R�_Depth to Water Table 'J-J'Qt. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe W Hardpan ❑ Previous Application Made: Yes ❑ No- New Construction: Yes 54, 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---------------------..___________..____._.___._. ❑ No. of compartments--------------------- ----Size--------------------------------Liquid depth---------------- ------- -Capacity----•------------------ Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line____-___.--_----• ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material-------------------------Depth of filter mater ial___..___------.-_.____ Total length-__._--____________-__.____..-.________-. W e Pit: Distance to nearest weIL.J. --------Distance foundation ____.-..Did nce to nearest to ye____�_�_r Number of pits--------I------------Lining material ize: Diameter • - Depth Cesspool: Distance from nearest well-----------------Distance from foundation-----------.--------Lining material____________-------_____.._.__.______ ❑ Size: Diameter--------------------- - --------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------.----_________________.__--... ❑ Distance to nearest lot line--- --- ------- - ---------- ----- --- - ------------------------------f----------------------•------ -------jCoun�fy Re odelin ncl/or repairing (describe): ... (---•- --- ----------------- - -- ----------------------------- -------------------------------------------------------------------------•-------------------------------------------------------------------------• ------------I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)____.. (Owner and/or j.•W- -- ------------------ -----------------------------------•----------------------------------(Title)---------------------------•----------------------•-�------------ Y•1�t-x- (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 APPLICATIONACCEPTED BY----- --------- -- ----------- ------ ---------- -- -------------------•-------------------- DATE---------fn--_.------------ --------------------------------- REVIEWEDBY------- ------------------------ --- --------------- ----------------------------------- ------ DATE BUILDING PERMIT ISSUED----------------------- ----------------------- DATES - ._..... Alterations and/or recommendations: \1C-----------•---- ---------- ---------------------------------- --- ----------------------------------------------------------------------•--•---- -------------------------- -----•----•------------------------•-------- -------- ------------------------------------------------------ -------------------------------- ----------------------------------------------------•------------------- ----------------------•----------------------------------------•--------------- ----- ---------------------------- --------------------------- -- -------------------------------------------------------------•-- ..- �.-6----- FINAL INSPECTION BY--------- - ------ �--------- -•------- ------ 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 145446 ATWOOD