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APPLICATION FOR SANITATION PERMIT Permit No. _______� ----------- __ (Complete in Duplicate) Date Issued l Dg-3&o --03�_'"______________ INA Applica-�ion is hereby made to the San Joaquin Local Health District for a permit to construct and install,the work herein described. Se This application is made in complia•nceywith County Ordinance No, 549.r J Z F � JOB ADDRESS AND,L CATICLN_ �- o 'l( ._ �+ = "t - Owner's Name ' `�• '---•- ---- -- Phone. Address------ ----- Contractor`s Name-- ------------------------------------------------------------- ------ Phone------------------------------------- Installation -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 Community system [IPrivate E] Depth to Water Table -------- ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ 01 Previous Application Made: Yes E] No © New Construction: Yes MNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted itpublic sewer is available within 200 feej.) r Mate i ----- ------------•- - Septic Tank: Distance from nearest well `�_ Distat c f o.9 f�pun�tion/+�---------_ .. � - 2/ No. of compartments_.._.__,__Zt..____ -- Size x-l�_ __---- -- `` •q I p. ------- - pacify-14 - - 71 --- --------Li uid de th------------- - ----Ca --- :. j Disposal Field: Distance from nearest wellDistance from foundatign o'. 16istance to nearest lot line C --------- 1 Number of fines___________ Length of each line__Q�� .__._-Width of #ranch-____ ___ __�-___-_______", 5i,} 1 Type of filter materitil_ . t� epth of filter material-______ _ _. ____.Total length.>_________ ______________ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------.......Distance to nearest lot line____________-_--- 1,.0 ❑ Number of pits----------------------Lining material----------------_-__---Size: Diameter-----------_:----------Depth___--.--------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------.---------.....Lining - material---------------------------------_--___--_____-____-__----___.___--___ ❑ Size: Diameter--------------------------------------De th---------------------------- ---------: ------LIuicl Capacify_--------------------------gals.. Privy: Distance from nearest well---_----------------------------------- ---------Distance from nearest'building----------------------------------------- El _________-____-______-_______- ______❑^ Distance to nearest lot line---------------------------•---------------------------------_____------------------=------------------------------------------------------ Rem odeling and/or repairing (de"s-c.r-ibe) -- _ ^ --- --- --------------------------------- - -- - --------- ---------- -------_--•-•• --- --- - -- - - '-- �-------------- --------------------------------_----------------------------_------_-----------------------------_--------------------------------------------------_------------------------------------------------------------------------ )+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. (Signed)........ ---------- �f. (Owner and/or Contractor)- i. By: '- ' .. ,� �! r w == --------- •----(Title) �r 'i� ,..''s .- (Plot plan, showing size of lot, location of system in relion to wells, buildings, etc., can be placed on reverse side)-. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -0-------------------- -•- -' ------------ ------- - -------------------------------------- DATE- ------•---------------------------------- -------- - REVIEWEDBY---------------------------------�..N\ -------------------- --------------------- DATE --------- BUILDING PERMIT ISSUED------ I——---- - -- - DATE------ ---.-----------------------------------------••-•-- C.PNat�ons/ad/or re�t.om en-,d�a_.i_ _ � , � � � -AlteriJam__--_- . ------ -•-- . -----1. .._ -------------- . - --- ---------------------------------------------- ---------------------------------------- -- - FINAL INSPECTION BY:... . ... j -------------------- Date---- .T -- - •--------- --W•---••- G I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West CA Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9 145446 ATWOOD