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�X / APPLICATION FOR SANITATION PERMIT Permit No. __ •5-------- I (Complete in Duplicate) ' Date Issued ____ _____ ---�___ I Applical-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 Coun,ty`Ordinance No 649 � 4 JOB ADDRESS AN r'LOCATION �'' �: �' � -- jj =]----------------------•- Q 1 :� --------------------- --------------------- Phonel.l. /._ - Owner's Name--- = E 4 __•,n- w --- - Address....... -�12., -- := = A---------------------------------------------------------------------------------------------------------------•------- Contractor's Name ! - •- --------------------------------------------------- -------------------------- ------------•--- Phone------------•-- Installation will serve:' Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ g ` ./0 0.'------------- Number of living units: ____:: umber of bedrooms .... Number of baths .. .... Lot size __-__-. __ __..•-_ Water Supply: Public system (Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Lo; No i 'Clay,Loam ❑ Clay E] Adobe❑ Hardpan ❑ LrJ Previous Application Made: Yes ❑ No New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)s Septic Tank: Distance from nearest well_ ."--------. Distance fro -0foun jion_-1.0.. No. of compartments--.-..... -------.-Size _. r __ _ ._Liquid depth........ ......_..__Capacity._.- Dis os I-Field: Distance from nearest well__*....____---Distance from foundation----. ------.....Distance to nearest lot line. pr ---------- of filter materSa -•� Length of each line..._._- Width of french......- _ f_..._-...- �----- Total length------------ --------------- Type i Number or lines....,.._ _ Depth of filter material ---------------- __.._ Distance from foundation......-_-.. ....................Distance to nearest lot line----------------- Seepage Pit: Distance to nearest well---------- ^ Number of its_ _ _ . .-.- ---------_----------- ----Lining materialSize: Diameter........i-----.-__-__Depth._ _ _ .._- -...... ............... p 1 N� Cesspool: Distance from nearest well-----------------Distance from foundation---------------.--..Lining material-. --- .-.-.___.__.._--._------ O i ❑ Size: Diameter------- ------------------------------Depth------------------ ------------------------------- Liquid Capacity------------------- .-.gals. N Privy: Distance from nearest well----_--------------------- ---- -------------Distance from nearest building-------------- - • -••-------------- ❑ Distance to nearest lot Gne -------------- ----------------------------••--------------------------------------------- i c Remodelingand/or repairing (describe):------ ------------------------------- --------••---•-----------------------------------••-----• -------•------------------•------------•--•----------- --•--•---------- ---------------------------------• ----------- ----------------------------------------- L ----- ---------------•-•----------------------------------- i------•---------------------------- -•------------- = --------------- . f ------------------------------------------------------------------•---------•-----------•------------------------------------------------- I 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. Si ned � � _ A" / ------------------------------------------------------- - ------------------------(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 APPLICATI N ACCEPTED BY ------------•-•-•-•--------- DATEZ`_...-------------------------------------------------- REVIEWEDBY----------------------------- -------- --------------------------------------- ----------------------------------------- DATE. - ---•------------------------------------------- BUILDING PERMIT ISSUED DATE........ -------------------------•------•-------------- Alteratio nd/ rec menl atians: �_ _::-- •---------------••------------ - -- -- -----•---•-•--------- --- I = [i... .t------------------------_ -------------..i.----------- -------------------.-- ---A-s-------64 t .......------------------------- . ... ..-....F---------------------.------------,----------------------.--------------------------------._-_.--------------------.-------------------_ -----_-._-------._-....__._. l FINALINSPECTION BY ..Gs.._-r�"3 ��-------------------•---------------- Date.--------- ------------------------------------ -------------------------------- I y 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 111 Es-9-2M 145446 ATWOOD 42-54 J