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APPLICATION FOR SANITATION PERMIT Permit No. ___ _-- I {Complete in Duplicate} Date Issued _____ TA plica-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 LOCATION_ .f__7� -lc}r"'lk Owner's Name..----Z-� /-S-----{X. f /__�o------------------------------------ -------- ----------- Phone------------------------------------ Address-------_---------- ----------------------------------- Address___________________ Contractor's Name----------- -: da ---------------------- ----------------------------------------------------- Phone----------------------------------- Installation will serve: Residence igApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _aR_ Number of bedrooms,3__ Number of baths _ _ Lot size __.__ ..__ __ ____________________ Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Table _ t. Character.of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cay Loam ❑ Clay ❑ Adobe Hardpan ❑ ! F Previous Application Made: Yes ❑ No [S� New Construction: Yes ❑ No [5 f,. TYPE OF-INSTALLATION AND SPECIFICATIONS: {No septic tank or cesspool permitted if public sewer is available within 200 feet.} S9,et• Tank: Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- - -------------------------,. No. of compar#ments_ Size--------------------------------Liquid depth--------------------------Capacity----------------------- Dispos Field: Distance from nearest well------------------Distance from foundation____.............. Distance to nearest lot line----------------- '� Number of lines-----------------------------------Length of each line-----------------------------.Width of french----------------------------------- y Type of filter material-------------------------Depth of filter material-----.-----------------Total length----------------_----- ................ .. SSe e Pit: 1�1� Distance to nearest well--'2k from foun fion__ .__.___:Distance to nearest lot iine_.._..��_._-.- if✓ i. Number of pits-----?�-------------Lining material_6do64"-kize: Diameter,.- --__-__-Depth.....------------------------ t. Cesspool: Distance from..nearest well-----------------Distance' from foundation------------- -_,:_ Lining material...____..____._____-__________-___ ❑ Size: Diameter --- ,---- Depth----------------------------------------------------Liquid Capacity- -------------------gals. \ Privy:_ Distance from nearest well--------------------------------------------------Distance from nearest building-----------------------------------------. , ❑ Distance tonearest lot line________________________ ____ ----------------------------------------------------------------------------------------------- Remodeling and/or repairing [d ;be):--------------- ___.---- ----------•-----------------------•------------------ •-------- escr -------------------------------------------------------------F------------------------------------------------ -------------------------------------- --- ----------- 4� -----------------------•------------------ -----•------------------ --------------------------- -------- I here6y 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. - a {Signed} ...' ` �r � i'_.. i' <_e ---------- -------( Contractor} BY: -----------------'' {Ti+le} , (Plot plan, showing size lot, locd'tion of system in relation to wells, buildings, etc., can be placed on reverse s'' e� a s = -• ` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.. ------=----==•-------------------------------?------------------------------ DATE REVIEWEDBY------------------------ - ------ -----------.---•-------------------- ------------------------------------- DATE---�`---------------------------------------------------- BUILDINGPERMIT ISSUED----------------------- ---------------------------- --------- =----------------------------- DATE-----------•---------------- ----------------------- i Alterations and/or recomme ations------_.---------------------------- ` ----------------------------------------- ------------ . ... ._._...._......----••-•------------------------------. •------------------------------------------------------- -- ----------- --------------------------- ---------------------------------- ----------------------------•-- ----•--------------------------------I--------------- -------------- y- -------------------------------------------------------------------------- ----------------------------------------------------- FINAL INSPECTION BY::- l ---------------- Dste J,I --------------------------------- SAN OAQUIN 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-5 145446 ATWOOD