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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 with County Ordinance No. 549. -----------E JOB ADDRESS AND ATION �_ ' '' s�` -----------•- ------------------------------------------------ Owners Name - Phone_ Address--- .-�J--�-------•- . F. --------•----------------------- J ContractorsNa --------------------- ---------- -------------------••---------- ---------------- Phone-----2.7 -_r-_� - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [3 Number of living units: _/-___ Number of bedrooms..__ Number of baths ./_._ Lot size/A fl-------------------•------•- Water Supply: Public system Community system E] Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob�' Hardpan ❑ Previous Application Made: Yes ❑ NOX New Construction: YessX 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--- -- --------------- ,� --------------- :? ,�r� ' "4L-�----Liquid depth__5�-- -- t -Ca acit QC. ----- No. of compartments.__ Size __. --- P Y S Disposal Field: Distance from nearest well.___Distance from foundatson-/�__r-..___.Distance to nearest lot line_________________ Number of lines------,!-----_------------ ---Length of each line------�Q--------------.Width of trench------- Type of filter material ----Depth of filter materiaL_1,9�"--_-.___.Total length1------------------- Seeps e Pit: Distance to nearest well..r�-v_------Distance from fou dation__/41___.._.___.Distance to nearest lot line__._ . Number of its--___ --...__Linin mate rial_ Size: Diameter--_ -..__.------_.Depth_.. '- p9 Cesspool: Distance from nearest well----.------------Distance from foundation.-.._.----_--------Lining material_______________________________ ❑ Size: Diameter-------------------------------------Depth----------- -- ------------------ --- --------------Liquid Capacity----------------------------gals. Q . f -_Distance from nearest building (N Privy: Distance from nearest well- -------�-------- -- ----------------- 9------ - - --------------•----------- `V ❑ Distance to nearest lot line---------- ------------------ -- --------------------•-----------••--------------------------------------------- --------------------------- l Remodeling and/or repairing (describe): -- -----------•-----------••-----------••-----------------------------------------------------------------•--------- ------------•-•--------------------- - ---------••-------•---•I----------------------------------------•------.--..-------------------........-------------------------------------------•-------------------------------- -------------------------------- ------------------------------------------------•-----------•---------•-----•------------••------•-------------••----------•-----•-------- ------•-------------- I hereby certify that 1 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) • �� ---------------------------------------------(Title)----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be p ced reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY - - --------------------------------------- ------ DATE-------------------------------------------------------- REVIEWED BY--------------------------- :n---- DATe BUILDING PERMIT ISSUED---------- - --- ------ ------- ----------- --------- -------------- DATE------- �---------------------- Alterations and/or recommendations:__--___._ .-� -- ----- --- -- ------ - / 9 ------ -------------- ----------- -- ---- --- - -----. - - � ----------•----- ---- --- --------•---------- - ----- ----------------------- --- - j FINAL INSPECTION BY:.... -------------- Date....------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 !North "C" Street Stockton, California Lodi; California Manteca, California Tracy, California ES-9-2M 145446 ATWOOD 12-54 Y � I�