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:APPLICATION FOR SANITATION PERMIT Permit. No. --_9-----7_---____- (Complete in Duplicate) ! Date Issued --- I-.Z • F Application is hereby made to the San Joaquin Local Health District for a permit to construct and inst'atl�th'o k herein described. This application is made in compliance with County Ordinan e No. S49. J08 ADDRESS AND LO ATION 4 W--7--- Owner's Name------- ,G - - - • ----------•------------------------ ------------------------------------------ Phone--------------------------------•--- Address---------------- �------ -- - " --- - ---------•--•-------•------- -•------------------------ -------------- ----•------------------------ ' r � Contractor's Name------------_- ------•--•- [ ---------- ------------------------------------------------ Phone-----------------------_----- Installation will serve: Residence ❑ Apartment House n—ommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _ Number of bedrooms .- -- Number of baths _s _ Lot size __ __" c __, J_f��------------ ---------- ____ Water Supply: Public system P'Community system ❑ Private ❑ Depth to Water Table 4111_i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay,Loam ❑ Clay ❑ Adobe 21-Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No P-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept Tank: Distance from nearest well__;______________Distance from foundation----------------._.Material------------------.------------------------------ f No. of compartments--------------------- -----Size------•---------------------_---Liquid depth--------------------------Caaci s Disp al Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- ' Number of lines_-_�-------------------------------Length of each lin e------------------------------Width of french------------------•---------------- ��%%%"' Type of fi{ter material-------------------------Depth of filter material-------------- --- __-Total length----------------------------------------,- Seepage Pit: Distance to nearest well_ /1-0941"_Distance fro foun ation ----------Distance to nearest lot line_____ Number of.pits____- _____________Lining material_�:�c__ _ ___ _•__.Size: Diameter__:A/_r.%.g--------Depth------ - ------------ 1 Cesspool: Distance from nearest well-----------------Distance from foundation....................Lining material---------------------------- _._-_. ❑ Size: Diameter----- -------------------------------Depth-------------- -------------- - - - -- -------- ----Liquid Capacity----------------------------gals. y Privy: Distance from nearest well----__----- --------------_---------------------Distance from nearest building_----------__-________ -------------------- ❑ ` Distance fo"nearest lot line------------------------------•------------------------------------------------------------------__--------------------------------- --- I Remodeling and/or repairing (describe)------- = _... -• •°-------- - - __________________________________________________________________________________ ___ __. __ _ __ __ ___ __.___-____ _ _- _ _ _. - . _________ __________________________.-_______.___------______________________--______._-__-____-________--________________________-_-__.__-___-__-____-__-__--__._______-__---__-____--__-----_-___.-_-___-___--_----_----_.-- 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 rul� and regulations of the San Joaquin Local Health District. (Signed) Contractor ' By: -------------= -----------(TitleI--- _ .22y- F - (Plot plan, showing size of lot, loc n of system in relation to wells, buildings, etc., can be placer oh reverse e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- DATE_—--------------------------- ----------------------- REVIEWEDBY------------------------------- DATE-__�v�-------------------------------------------•------- BUILDINGPERMIT ISSUED----- --- ---•------------------------------------------------------------------------------- DATE-------Qs�----------------------- --•- ----------------- Alterations and/or recommendations: (Y ---=----•------- - ------- ------------------------ •-----------lV - ------- --- ---- -------- Date.--- ---------------------------------------- ' r f FINAL INSPECTION BY---------- - --- _ _--:_:---.------------------- - � Q.------`'�----�� 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 I E5-9 145446 ATWOOD i