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APPLICATION FOR SANITATION PERMIT Permit No_ ____ _ __ ___________ (Complete in Duplicate) Date Issued _____ ____ _.S�_.. 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. 549. JOB ADDRESS AND L ATION -- - --- ---- Name ----------------------------- -------------- Phone- �--------------------------- Owner's Address..--_------------------- -- Contractor's Name_________ _ __ _ -- ----------------------------------------- • -- - - ------------------------------------------•---•--- Phone--------------- ------------------- Installation ---•------•--•--•---------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _._ Number of bedrooms 1-. Number of baths __/___ Lot size ______________ I Water Supply: Public systeT*4f Community system ❑ Private ❑ Depth to Water Table -------- ft. t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam'[] Clay ❑ AdobeA Hardpan ❑ Previous Application Made: Yes ❑ Noj6 New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic Tank: Distance from nearest well------------------Distance from foundation------.------------Material ________.__._____.___.___-____.---__-____._.-__. No. of compartments----------- - -----------Size--------------------------------Liquid depth------------------------._Capacity----------------------- Disa fiel spod: Distance from nearest we!I�rtrx�. Distance from foundation-- _�.e.__....Distance to nearest lot line____- Number of lines_______ _______________ ______Length of each line.._.__.��._._._._ -french -------- Number length___._______ a_'_ Type p X Seepage Pit: Distance to nearest well------_---------------Distance from foundation--------------------Distance to nearest lot line----------------- i Number of pits----------------------Lining material-----------------------Size: Diameter----------.------- Depth--------------------------------- r� Cesspool: Distance ft•om nearest well--------_-----___Distance from foundation-------------_____.Lining material-_._-_____.__.___._________________- ❑ Size: Diameter--------------------------- ----------Depth--------------------- ---------- -----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearesf building----------__.__-----._._._____.__--_.___. ❑ Distance to nearest lot line---------- ----------------------------------- •----- -------------•e --- -----•------•--------------------------Remodeling and/or repairing (describe) �' L_.�� =" ' •-•------- -----------•---------------------- - } x 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)--------- --------- 1---------=- -- ---------------- -- ---------------------------------------- ---------Aedo wner and/or Contractor) By:..... ----•----------------—- ---- -=------------------------------------------------------------ -------------(Title)- -----`------------- --- -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be perse side). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYVDATE .- REVIEWEDBY---------------------- ----- - - ------------- ........ ---• - ---------------------------------- DATE-YS-'T"'----------------------------------------•------ ' BUILDINGPERMIT ISSUED--------------------- -------------------------------------------------- ----------------------------- DATE---- ------------------------------------------------- Alterationsand/or recommendations:--- ------------------------------------- -- -----------------------------------------------•------- -------------------------------------- - --- - --------- ----------------------------------------- - ------------------------------------- - -----------------------------------_- _----- ---------------------------- ------------ - ------- - ---------------------------=------------------------------------------------------------------ ------------------------------------------- •------------------------- ----------------------------------------•------ , /fir FINAL INSPECTION 4BY:- -.--.-----4 rf- -------------------------------- Date..... _f.! _.�._ ------------------------------------ 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-9-2M 145446 ATWOOD 12-54 _