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APPLICATION FOR SANITATION PERMIT Permit No. .__ _ __a (Complete in Duplicate) Date Issued I 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. 11 JOBADDRESS AND LOCATION.. . -21-e-67 . Owner's Name-----PWR_v46I ` p = ------ ----------------- ---- Phone----------------------•------------� Address------ f 9---------III -------- �, Cont'ractor's Name..._ -------�=---- - - ------------------------------------------------------- Phone------------------------- 11' Instal'ation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] Motel [j Other E]E Number of living units: __/_-__ Number of bedrooms __,':7--Number of baths _)-____ Lot size (. ----------------------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan ❑ �� Previous Application Made: Yes ❑ NoNew Construction: Yes > _ No ❑ F TYPEF OF INSTALLATION AND SPECIFICATIONS: 11 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 4 Septic Tank: r • oce from nearest w•eEl-----------------Distance from foundation--------------------Material _____________..____.. ❑ ompartments------------ -------------Size--------------------------------Liquid depth------------- ------------Capacity---------- --------- Disp sal Field: Disfaote from nearest weft_._._____._...._Distance from foundation---______-----------Distance to nearest lot line________._._:___ ❑ of lines-------------- ----------------Length of each line--------- -------------------.Width of trench---------------------- ---------- IType67 filter material------------------------Depth o = ------------------.Total length------•:---------------------------------- Seepage Pit: Distance to nearest well____ _ -- -- • nce fro found`ntion_ _ . ^ 11 Distance to nearest lot line._- -� , pit Number of pits_____ ..____ Lining tenialla- $-(0 ameter_____ De th--- -- cesspool: Distance from nearest well--------------. _Distance from foundafio ___________________ Lining material__._.____._____._.__. __________.. Size: Diameter----------------- ------------------- th- ------------------ ------------------- ------_Liquid Capacity---------- ----------- ----gals. Q Privy,,. Distance from nearest well-------------------------------------------------Distance from nearest building----------------------•------------------. \ ❑ Distance to nearest lot line--- - ------------ -------------- V E Remodeling and/or repairing (describe):-------- ---------------------------- -------------------------•--------------•---------------------- - "d _________________________________________________________________•____-_____.______.-__-___--__________________--_-______________---__.-__________. . _____________________ ______________ _______________________ --_. -.______________________--___-__________.______.__._ _____________________________________________ _________.________________..----------------------------------------------------------------------------.----------------------------------------------------- 11 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State S, d rules and regulations of the San Joaquin Local Health District. i - - rer (Signe d)--------- ------- -=- ----- -------- -- - ----------- =_ and/or Contractor) By=----- ------ ---- --- --------(Title)---- n------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 11 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_______________________ __ --- ----- DATE REV BUILDING NG PERMIT ISSUED________________________-_-_ ". -"- _"-___.--________________.____.__. ______.._ TE ___--_._._-__ `_J _.___-_- -"_--- ------------- Alterations and/or recommendations: - -- ----------------- � ._ -----------•------- .---I---•---------------------- - ----- b -------------------- - A. ..Z-1 - ' -- ---- ----------=----------------------------- ----------------------- ------------------------- ---- ----- ------------------------------------------------ -- FINAL INSPECTION BY: `-- J- Date.----- :I SAN JOAQUIN LOCAL HEALTH DISTRICT ,i 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C' Street I€ Stockton, California Lodi, California Manteca, California Tracy, California I ES-9l� 145446 ATWOOD -