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D APPLICATION FOR SANITATION PERMIT Permit No. /--._.. (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 ith County Ordinance No. 549. x_,(2_— 170 -OS 5 l- ' �`ANDOATION------------------ � Phone.---- ------- it; ---------------- �5nef saEe-- - - -- •----------- -- ---- •-----= -- ----- -- -- ------------------ --------------------- } e -------------- Address ... 1 - Contractor's Name-------- ------ -- --------------------------------------------- --------------------------•------------------ Phone--------------------_------------ Installation will serve:' Residence ❑ Apartment House ❑ Commercial ❑ Trailer ourt tel ❑ Other ❑ Number of living units: _A___ Number of bedrooms .-_'YNumber of baths',____. Lot size ____----. ___ � �----------------- gg�� -- --•-_---- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table __v---19T. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ Adobe Qr Hardpan ❑ Previous Application Made: Yes ❑ No &] New Construction: Yes O' No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ` - (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - Septi Tank: Distance from nearest well_ __ Distance fro foundation-----t_Q-------Mate ria _ _____________ ____________ 'r __Capacity, ' EK No. of compartments-------A ' Size . _ '--Liquid drepth p ty...- �' - Disposal Field: Distance from nearest well___e.7 G?_.__Distance from founda�t o 12- _-1--i------- to nearest lot lin ____J Number of lines______________a.____._______....._Length of each line_____-----.Width of trench------- -_ ._`-r----_______ Type of filter material__ -►r +:_-Depth of filter material....___J_.�_______Total length____..' ""��-`�_.__- tw Seepage Pit: Distance to nearest well_____________________Distance from foundation--------.---------- Distance to nearest lot line---_------_!--/' ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------.------_t.__Depth.--------------------� _ Cesspool: Distance from nearest well-------_---------Distance from foundation------------------- Lining material__ __.._____-__---- �_______ `f. Size: Diameter ... --------------------------Depth--------------------------------------------.--------Liquid Capacity------!Imf,---- �9als. __.___.___-.Distance from nearest building____-___4 Privy: Distance from nearest well-------------------------- --------- -----q------------------------------------------- ------ ❑ Distance to nearest lot line------------------ ----- •----------------------- Remodeling and/or repai ' �(describe]t__ __..____ _. _ ..�--- -=- ----w:...----=--- •tet---=- -= --- -- ------�:-•-- - --- --- -----------_ -� --- ---:- - �:----¢Q-�--�---�--�- --------- - --------------------------------------------------------------- ------------------------------- ----•--------------------------------------------------- -------------------------------------------------- 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. Signed ----- ------(Owner and/or Con trac+or} 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 APPLICATIONACCEPTED BY---------------------- ----------------- ------------------------------------------------------ DATE---------------------- -------------- •----------- REVIEWED BY------------------------ ---------- --------- DATE------------ - - -------- BUILDINGPERMIT ISSUED_.------------------------------- -------- ---------------.... DATE--------._---_-------------------------- ----------•---- Alterations and/or recommendations:----------_--------- ------ ----------- --------------------------------••----------------------•--------- -----•----•--------'-----------------._.-------- •---------•------------------- -- --------------------------------------------------------------- -------•--•---------•------------------------------------•--•--------------------------'-------------•--••-------_- � --------------••---------•--- F ------------------------------------------------------------------ --------------------------------•------------------------ -- ------------------------------- ------------------- ----- --- r 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 E5-9-2M iasaaa ATWOOD ,z-sa