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r APPLICATION FOR SANITATION PERMIT Permit No. ._.lOf.�........ (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. , R JOB ADDRESS AND LO ATION... ?o" - ---------• ------------ ----- •-------- -- ' --- -•-- J- -- ------------- Owner's Name-•r--�-- . ----- -----• . . .......... ----- ------ Phone.........................----•- . Address----1• .1. ......_. .......... . -- ...------• -- ----- 1 Contractor's Name............-•--••--------•-----------------•------•-------•---.._._.......------..................................................... Phone................................... Installation will serve: Residencety"1 Apartment House E] Commercial E] Trailer Court ❑ Motel ❑ Other ❑ �� Number of living units: __--l__- Number of bedrooms ----I--- Number of baths ......[ Lot size -------- Water _____--Water Supply: Public system ❑ Community system ❑ Private '(�Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 0� No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewjr is available within 200 feet.) Septic Tank: Distance from nearest well.$i� a_ istanct fro�oundation____/.. f l 6--------.Ma er-a1 _ --- .... No. of compartments._-----.'7/-------- . -Sizej..x ___Liquid de ,th---_- Disposal Field: Distance from nearest ell-_ istance from foundation...._.I - istance to nearest lot line__...... Number of lines---------�---------------------Length of each Width of trench_._. Type of filter material-------------------------Depth of filter material__-.-__--_.-- --._-.Total length.......................................... Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line__--------------- ❑ Number of pits...............:......Lining material-----------------------Size: Diameter..................-----Depth--------------------------------- Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material__---.-_.--._..----__--_______---_---. ❑ Size: Diameter---------------------------------- ---Depth...------.......-----------------------------------Liquid Capacity........................•-_9-als Privy: Distance from nearest well-------------------------------------------------- from nearest building__-_---.-_._---_______-__---._--__--_-_. ❑ Distance to nearest lot line-------------------------------------------------------------------------•---•----•------•------••---•---•----•-----------------------•------- Remode dor re ai in describe :.. . ....1`.____,,,-/f„____l:0.•-..-.3.a— f `------------------------------------------------------------------------------------------------------------ ----------------------- ------------------------------------------------------ -----------------------•--...-----•---..._.....----------•-•-----...---------------------------------------------...-----•------•-•-•---------- ------------------------- --------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1 hereby ce ' y that I have prepared this application and that the work will be done in accordance with San Joaquin County ; r ordinances laws d rules and regulations of the San Joaquin Local Health District. 1�! (Signe ..... . -- --------------------------•_----------•---•------_---.--------------------------------------(Owner and/or Contractor) By:---------------------......................... - ---------------------------------------------------------------------------------(Title)-------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can te-..placed an reverse.side). --- -- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- -------- -----------------------• -------------------------•---.....------ DATE-----------•---•---•----------------•---•-. -- ---------- REVIEWED BY----------------------------------------------- DATE..... w' � x' --------- BUILDING PERMIT ISSUED --------4-- - DATE---------------------------------------•-------------------•- Alterations and/or recommendations:--------- ------------------------------------------•------------------•-----------------....------------_.. -------------------------------•---------------------------------------------.---..............................................----------•-------....------•----•------•------------•---•--•-------------------------------• s... -------•-------------------------------- -----•------........................................................................................................................................................................ ----------------------------------------- ----------------- ---- ----------- --------------------------------------------------------------------•------------------------------------------------------------------- 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-9145446 ATWOOD