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p APPLICATION FOR SANITATION PERMIT Permit Na. _ (Complete in Duplicate) D ate Issued _D!_3. 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. 544. JOB ADDRESS AND LOCATION___.. 1} r Owner's Name-------------- ..fir------ --- - Q� ------ ---- ------------------------- ----------- Phone Address__. - ontractor's Name_________ ---------------------- ---------- ---. _______________ .._ Phone Installation will serve: Residence I�rrient House E] Commercial [I Trailer Court ❑ Motel [I Other E]. "_�r Number of living units: __/"" Number of bedrooms __.: Number of baths Lot size .____�_�i7 ------------- Water Supply: Public system ❑ Community system ❑ Private to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam Clay Loam Clay Y Y ❑ y ❑ 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.) -a.� Septic Tank: '""-Distance from nearest well___ �-"Distance from foun`datio - ® � IT-- mate No. of compartments--- �------- ---Size---p -S-�J �iquid depth------- - --a-�l-.____----Ca Capacity -�..�----_- -- �- Q- Disposal Field: Distance from nearest well:�0_4—Distance from foundation__ 0.8-.....".".Distance to nearest lot line.—S,__ Number o{ lines - ------ _ Length of each line------/_.,RC1Width of french-----�-�----"-"--- -- Type of filter material___. __ _._._.. ".Depth of filter material----- 18 ---- • .Total length-----1�0------------------------'�[ Seepage Pit: Distance to nearest well-._.__-__.__--.--___Distance from foundation___________________ Distance to nearest lot line__________-______ ❑ Numberdof pits----------------------Lining material-----------------------Size: Diameter----------------------.Depth--- ---------------------- ,. _ O Cesspool. Distance from nearest well__,__________Distance from foundation------ -------------Lining material--- ----------------------- ❑ Size: Diameter-------------------------------- - ----Depth------------- --. - ---" Li quid Capacity _" ----- li - --- ------ gals. �!YX:.a�,,,,�;:.�:I:::,.Distance;,from,nearest;k„elle __ _ .. — -~ _ F -------- - - Disterrce'#rur earesf builain` ❑ to nearest lot line g------------------------------------------ ----------- Distance” Remodeling and/or repairing (describe)__________ ______ -------------------------------------------•--------•-----••----------------------------------------r11 --------------------•--------------------------•---- -- -------------------------------------------------- ------------------•--------------------•-------------------------------------------•------•----------------- -----------•----•---••----------- -- i -------o I hereby certify that 1 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 ----- -- - `--� 9 ) '�' _r - --- ------------------ (Owner and/or Contractor) BY:--------•---- -----------------------------------------•- ------------ -- - ----- ----- -- •---- ----------(Title)---•---------------------------............ ................... '—[Plot OW6 showing size-of lot;location of system in-relation to w•ells,-buildings, etc., can"-be placed-on-reverse-side'):,_ -•�M- -.� FQR-DERARTWNT USNLY APPLICATION ACCEPTED 8Y_____ -r_ "-. _�_ V ATE � _ 71-rREVIEWED BY -- ----- ---------------- -------------------------------------------------------- . DATE__-------------------------- ------------------- -- BUILD IN PERMIT ISSUED- ------------ ---------------- -------------------- DATE-------- Alterations and/or recommendations:_____..__._. __--------- -------------------------------------------- ..._ . u ---------------•--------•- ---------------------- -----•----------------------------------- ---------- ---------------------------------------- - - -------------- FINAL INSPECTIOND /_ _ r --- ---------- ---------------- ate_... .. " 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-9-21M 145446 ATWOOD 1y-54 R� I