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APPLICATION FOR SANITATION PERMIT Permit No. A�_V._--- <br /> (Complete in Duplicate) r1/ y/ <br /> . _ <br /> Date Issued .._lLIS_.//_ 7�._. <br /> t <br /> Applica;lion 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 /> , s - <br /> JOB ADDRESS ANDLOCATION��,I * �.�- --_yam??'._. .. __..�� ...... <br /> �� -- -fL__ ( <br /> Owner's Name---------�:- ..... ----------- Phone----------------------- -- <br /> Contractor's Name,/. ` -----------------------------------------------------------------------------------------------•----------- Phone----------------------------------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer's& Motel ❑ Other ❑ <br /> Z <br /> Number of living units: /----- Number of bedrooms Number of baths ___ Lot size _____________________._ <br /> Water.Supply: Public system ❑ Community system ❑ Private, ] Depth to Water Table kQ__ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam,M Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: Yes ❑ No 0 New Construction: Yes M No ❑ <br /> TYPEYOF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> F1 <br /> Septic Tank: Distance from nearest•weh---,�".O___„--Distance from foundation-_1P-_------_.Material---� LA= <br /> No. of compartments v` Size ------ Liquid depth- Capacity-,? ------ <br /> Disposal Field: Distance from nearest well._,%-_.......Distance from foundation___,�_8---------..Distance to nearest lot line.....,-___-- <br /> Number of lines---- �.� ��. - Length of each line-----O________________.Width of trench----. _�_..........._...._. <br /> Type of filter materiai_j .%m�`;f...Depth of filter material.._ ®_.._.__.Total length------------------------------------------ <br /> Seepage <br /> __ a_'________________________ _Seepage Pit: Distance to nearest well---------------_--_--Distance from foundation--------------------Distance to nearest lot line-_---...__-_.-__. <br /> ❑ Number of pits.--:_!-----------------Lining material-----_-----------------Size: Diameter-----------------------Depth-------------_------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation______-............ Lining material-_---- ------------------------------ <br /> El Size; Diameter------` ----- ------Depth---------------------------------------------------Liquid Capacity---------------------- ---•gals. <br /> Privy: Distance from nearest well.... -------------------------Distance from nearest building------------------------------------------ <br /> --- .----__._--____-__ <br /> ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------- <br /> � - Yom, - <br /> Remodeling and/or repairing (describe):--------- --------------- --•------ ----------------•-----•-- --•---------------------- ---------------. ---------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------•------ --------------------------------------------_---•----------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)----------- ------ ------------ ----------------------- - -- (Owner and/or Contractor] <br /> By:.. ------- ---------- ---------------------------------------------(Title)---------------------------•-- -------------------------------- <br /> (Plot plan -showing-size of ,location-of-systemTin relation to wells, buildings,-etc.,-canbe-placed-on reverse-side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----- r DATE [ -� _'`5 <br /> --- <br /> REVIEWEDBY------------- ----------------- ---------=-- ----- -- ----------------------- ------- -------------------------------------- DATE <br /> BUILDING PERMIT ISSUED--=------------------ ---------------- --------------------------------- ------ ---------------- DATE------ -------- --------------------------------------------- <br /> Alterations <br /> --•----------------------- -Alterations and/or recommendations----------- ---------------------- .......... ---------------------------....----•--;•-------....----•----------------------- --......_.------------------------ <br /> --------------------------------••-•----- --------------- •------------ `------------ ----- ----- ----- .--------------------------- -. <br /> ----- <br /> --- --- -----•-------------------------------------------------------------------- <br /> ---------- ------------------------------- ------------- -------- ­-------------- ------------ ---------------------------------------------------------------------------------------•- .-. ---------------- <br /> FINAL=INSPECTION BY------- ------ ---•-•---•--------•------------ -------------- Date--------------------------------------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 1 300 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 />