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APPLICATION FOR SANITATION PERMIT Permit No. -----z (Complete'in Duplicate) ,ter _ 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. it This application is made in compliance with County Ordinance No, 549. JOBADDRESS AND OCATION------------- ------------- --- --------- ---------- --------- --------------------------------------------------------------------- --•------------ !�i --� Owner's Name ... i -- -- -- ------- - - Phone . Address _ . lAJQ Ipe Contractor's Name---------------------- - Phone --------- Ii Installation will serve:' Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: !------- Number of bedrooms _ Number of baths ________ Lot size ___________________________________________________________ Water Supply: Public system`g Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ 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.) Septic Tank: Distance from nearest well------- -- Distance from foundation___________________Material------------.------------------------.__--__--__. No. of compartments-- ------- --------- -----Size-------------------------------Liquid depth--------- ------ ........Capacity----------------------- 4 Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line.___.___.________ Number of lines-----------------------------------Length of each line----------------------;-------Width of trench----------------------------------- Type of filter material _._ -------___------___Depth of filter material--------------------- Total length---______._____________________-_____-._ Seepage Pit: Distance to nearest well____.._---------------Distance from foundation--------------------Distance to nearest lot line__.___..______.__ ❑ Number of pifs......................Lining material-----------------------Size:Diameter_-------------.------.-Depth rr------ --�----------__-------------- Cesspool: Distance from nearest well a -_____Distance from foundation , __________Lining ma#eriaL_._.a`_•��t ----___.______- Size: Diameter_ V-gyp-- - ----------- - Dernth ------- -------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-- '-'-'-------'-'-'---- ..------------------ Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line.-'-'-- ------------------------------------------------------------------•----------------------------------------'------------------------ Remodeling and/or repairing (describe)--------------------------------------- ---------------•-•------•---------•--•-------------------•---------------------------------------------------- - ---------------------------------------------------r7---------------------------------------------------------------------------------------------------------------------------------------------------------'------------- 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 Contractor) Tale By:---------------- (Title) (Plot pl4�hq 'n size f lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). V i FOR DEPARTMENT USE ONLY APPLICATION ACCEP 13Y'_"( -- ---- ------- ------------------- -------------------------------------- DATE------------------ -------------------------------------- REVIEWED BY------------ ----- - - - --- t -------------- ----------------------------- DATE---4}/-/ BUILDING PERMIT ISSUED---.--- --- --- --- -----•------- -------------- - DATE-----/_ -- ------ r Alterations and/or recommendations--- ------- -----------------------------------------------•------------------------------------•-••-----•---------------------------------------.._..-..------- + ----------------------------•--•-----••-------------- ------------------------------------------------------------•- •------ ---------------------------------------------------------••-------------------------------------- i{ ---------------------------- ------• ------------ --------------------------- ------------------------------------------------------------------------------------------------------------------------.-----•------------------- --------------------------- ---------------------------- - --- - ------- ------ --------- -------------------------------------------------'---------------------------------- •------- �e-..---•----------- FINAL INSPECTION BY:.---- ------ ----- ---------- ---------- Date.-- ------ --------- -------I------------------------------------------------ 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 E" 3-2M 145446 ATWOOD IZ-54