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PPLICATION FOR SANITATION MIT Permit No. . 3` in Du licate 0A (Complete Duplicate) / /sr 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 Count Ordi ante No. 549. wv JOB ADDRESS AND LONGATION--- ---------- ----- - -•-:-"-- -- -'------- -------------------- ------------- -------------- `'__".._ s- --- Owner's Name__!-!_te:. rt" r ----------------- PhoneH. Address--- 1 ---------- - - --................-.................._.........---------- --•--------------- ---------------------- } ----------------------------------- Phone------•----•------•-•--......- - Contractor's Name---------------------------------------------------------------- -••-•-------------------------------------- -•- Installation will serve: I Residence ❑ ' Apartment House ❑ Cornhiercial 0 Trailer Court ❑ Motel ❑ Other ®� _ Number of livinig units: -------- Number of bedrooms -------- Number of baths --------- Lot size ---------- ----------------- _ Water Supply: Public system El Community system ❑-Private �epth to Water Table -------- ft. Character of soil to atdepth of 3 feet Sand ❑ Gravel I Sandy Loam'E3- Clay Loam ❑ Clay ❑ Adobe 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.) I ' Septic a4: Distance from nearesf well__.._ Z- _Disfan4e from• ofou ation-----_________-----Material-i. -_-_--_____- ___.--_-- .__.._.-- No. of com artments____________ _ f _. ✓ :___Li uid de th.____ Ca acit ?v Q_d.___ p Size. '- q ,/ pt ----- ------ - p Y-----� - ! Dispos I Field: Distance from nearest well._f. a_Distance from foundation------T�-#..-.Distance to nearest lot fline-___�_ _____ p7 Number of lines________A--", __ _________.;Length,of each line------------ Width of trench----1 +.._- " ` '" Type of filter ma "i t{ I�" t g ` .� h of filter material----- ..r-- -._----_Total length -- SeepaA,p it: Distance to nearest well__Z+�__0..___Distant from fqu dation--- _ ---_-- Diptance to nearest lot line--____- __-__- Number of pits- .__._,. __ 'Lining material_____.. ` p ' 7r t --- ------- ------- ize: Diameter . ..De tri-------1 ` Cesspool. istance from,nearest weld_________ Distance from foundation--------------------Lining material------------------------------------- El Size.rrriiiSize: Diameter -- -------Depth-------------------------------------------- -------Liquid Capacity----------------------------gals, Privy- 'Distance from nearest well----------------------------------...............Distance from nearest building--------------------------.__.-..-..---..- Distanceto nearest lot line-- ------ --------------------------------------------------------------------------- ------------------•---- Remodeling and/or repairing (describe) r--------------------------------------------------------------------------•-••--••---------------------------------------------------- -- --- - ' --------- -------------------- -..L ----------------------------------•------------------------------------•-------- -----------------------=---- ---- - --------------- ------• ------- = ," ---------------------------------------------------------------------•-------------------------------- F. ---- ---------------•----------------------------•---------------------------•-- --------------- L hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)_ ��'�'? ... ------------------- ---------.-------------.----(Owner and/or Contractor] By: (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-- ------ ------- --------------------------------------------------------------------------- DATE--�------------------- - - ---------------------------- REVIEWEDBY---------------------- ---- -- ----------------------- ------------.--------------------------`DATE -W------------------------------------------------ BUILDINGPERMIT ISSUED-------------------------------- - ------------------------------------------------------------------- DATE---------XtN---------------------------------------------- Alterations and/or recommendations-------------------- -------------- ----------------------------------------------........................ -------------------------------•------------ ----------------------------------------------------------------•-------------------- --------•------- •----------- --•-------------------------------•-----------•----------------------•-•=-----------•--------------------- --------------------------------------- -------------------------- ------- - -- -- ---------------------------------- --------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:.. -•--------------------=---------------------- Date.... -�_ � � i 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-9-2M 145445 ATWOOD 12.54 J ��. 1r