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APPLICATION FOR SANITATION PERMITNo"� (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 with County Ordinance No. 549. JOB ADDRESS A D LOCATION_ _'_C.._I ----- -- -------------'-- --_- - �-------- r.----.------- vy Owner's Name----- - ----------------------------- l.2 •- Phone----------------------------------- Addres Contractor's Name-------;,�'�---------------------------------------------------------------------------------------------------- ----- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [] Number of living units: .__---- Number of bedrooms .-.A- Number of baths ---/--- Lot.size _______1 ..___._________________ Water Supply: Public system ❑ Community system ❑ Private P14 Depth to Water Table.o_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clla�yf❑ 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.) tp Tank: Distance from nearest well---�-Distance from foundation---.__.._.Material--------------------- _____________________ ��le tic No. of compartments-- ---------- -------'--._Size--------------------------------Liquid depth--'-'----....'-' ---------Capacity------ ----- -------- Disposal Fie Distance from nearest well--I&_-----Distance- from foundatio'nL------l_�-_.Distance to nearest lot 1ipe._. -�0___. Numbe of lines_--__---_-/- . � �, �_Length of each line`----`T Width of trench___. _`�_.—___________________ Type or filter material__ .1 _Depth of filter material-__-.�.4�.......Total -length- ____________________ Seepage Pit: Distance to nearest well-----------------__---Distance from foundation--------------------Distance'to nearest lot line----------------- El Number of pits----------------------Lining material_----------------------Size: Diameter----------------------.Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation...._- °____ Lining material-----._------------------_-.________- ❑ Size: Diameter--------------------------------------Depth_'----------- ••-----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------- _________'__._._._..____.__._Distance from inearest building--------------------------------- -------- ❑ Distance to nearest lot line____.______________. '-� TM ' � Remodeling and/or repairing (describe)-------------------------------------- ---------------------------------------------=--------------•--•------------:------------•------------------------ ------------------------------------------------•-•-----------------------------------------------------------•----------•-----•------------------------------------- ----•--------------------------------------------------- i ----• - -•----•-•---•-------------------------------•----------------------------•----• ----............----•------ •---•----------------•--------------------- ------ ------------------------------------ ------------------•---•-----------••-•------------------------------------------ ------------------------------------------------------------------------••--------------------- 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 M `�' (Owner and/or Contractor) --jitle -------------- ' ----------------- (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 APPLICATION ACCEPTED BY------------------------------------ -- ---------- ---- " ----- DATE------------- REVIEWEDBY-------------------------------- ------ -----'---------- ------------ -------- -----------• DATE--------- ,.. BUILDING PERMIT;'ISSUED----------------------------------- ----------- ) DATE. ------_- ------------ Alterations and/or recommendations--------------------------------- -- - -'-' -------•------------------------------------•--------------------------------------•------------------------- ----------------------------- ---------------------------------•- •-----------------•-------------------- ...------------------------------------•------•--------------------------------------------------------.... -------•---- ------------ FINAL INSPECTION BY:_ - Date. - '.. -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West dao Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9 145446 ATWOOD ' Yi: