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l[ APPLICATION FOR SANITATION PERMIT Permit No. <br /> ` (Complete in Duplicate) <br /> Date Issued ___.. <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> ll <br /> JOB ADDRESS AND LO ATI N---- _ -�--- ---------..._ - ---------- v <br /> Owner's <br /> Name.................. -- . ....... • . ............. ----------------- -------------------------------- Phone------------------................. <br /> Address.......... 1 <br /> Contractor's Name Z�Q'1�Lt. Qr f -------------------------------------------- Phone................................... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ---I--- Number of bedrooms __Number of baths ----J.. Lot size ------------------------------------------------------------ <br /> Water Supply: Public system ❑ Community system,Z Private ❑f Depth to Water Table .9---- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam g Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yes No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public s wer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well'_____ __:_Distan a from foundation_.._.._ _.___._Mat rial..._ ': -"�-�� <br /> 1 - - -------- <br /> [� No. of compartments___.'Y._ --------Size__;...\/_d__).(� j?1iquid depth_____.4� -_ -_--_--capacity...1_.. 0n.. <br /> Disposal Field: Distance from nearest w __ .. _ .._ istance from foundation----- Distance to nearest lot line-__� <br /> ON Number of lines............ ..... ... ... .Length of each line,3�_r.. ,$�-:_` ': .Width of trench.....�,,f._l�............ <br /> Type of filter material..,S�t�epth of filter material--------1-9-------Total length------ ------------------------ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line----------------- <br /> El Number of pits----------------------Lining material-------------------.__.Size: Diameter-----------------------Depth--------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------.-----..___.Lining material----------------------------_--______. <br /> ❑ Size: Diameter--------------------------- ---------Depth---------------------------------------------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well_____________________________________ ___________Distance from nearest building__-_----_--__._-___--_---_---._----------. <br /> ❑ Distance to nearest lot line----------------------------------------------------------------------- --------------------------------------------------------------------- <br /> Remodeling and/or repairing (describe):........................................................................................................................................................ <br /> --------•-----------------------•••----•-•------------•---------•-----------•-•--------------•--------------------------------------------------------------------------------•--••---------------------------------------- <br /> -----------------••------------•--------------------------------------------•---------------------------------- -------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------- ------------•-----------------------.....---•--------•----------•------........ ---------------------------- <br /> I hereby certify that I have prepared this application and that the work will be One in accordance with San Joaquin County <br /> ordinances, a laws, and, rules an �*ons San Joaquin Loca Health istrict. 9 <br /> (Signed) - -- ------- --------�___------ •- - ---------- _- ner and/or Contractor) <br /> By: .-----•------------------------------------------------------------------------------------------•-------------------....._ (Title)------------------------------- ----- C <br /> (Plot pla showing size of lot, location of system in relation to wells, buildings, c., ca be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--------- --------------------- -------------------- ------------ DATE--------- n <br /> REVIEWED BY-----------------------_---- --------- -------------------- ---- - DATE----- ;::.. <br /> BUILDING PERMIT ISSUED...........------------------------•-------_..._ . .. - DATE. -- ------- <br /> Alterations and/or recommendations-------------------------- ----- --------' - - <br /> ------------------------------------------------------------------------------------ -------------------------------------------------------------------------------••----------------------------•-----•---------•--•-----•. <br /> --------------------------------------------------------------**-------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----•--------•-----------------------------------------•------........ ------------------------- ....--------------------------------------------------..........---------------------------------------------------•----- <br /> .......................................... --------------------------•----- --------- <br /> FINAL INSPECTION BY------- --------------------- --a_..._.. Date. .------.....-•------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9 145446 ATWOOD <br />