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t ' a APPLICATION FOR SANITATION PERMIT - Permit No. _.�. 3 --•. ('" Y (Complete in Duplicate) 4,/ / Date Issued Tl---} Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. A This application is made in compliant County Ordinance No. 549. JOB ADDRESS A LOCATION - -------- ----7---I-------•---•• . Ad Owner's Name------ -..0- ------ ----- --- ---- ---------•------------ ---------------------------------------------------- -. Phone------------------------------------ Address- ---------- ----- ---- Address -- ---- -- ---•-- ------------------••--------------------•----•----------------------• ---------------- j� Contractor's Name__ `•. 8�—--- . -._ - ` ----------------•---------------------------- Phone Installation will serve: Residence 9 ,epartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f Number of living units: __ ---- Number of bedrooms .2,r Number of baths -_.1.-_ Lot size --_ -- 1------ _ ________________. ---- # Water Supply: Public system Z—Cammunity system [❑ Private ❑ Depth to Water Table'.5-0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam-E] Clay Loam ❑ Clay ❑ Adobe 1'Fd�an ❑ Previous Application Made: Yes ❑ No jg.. -Wew Construction: Yes 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-41-Oto-t_Dist once from foundation------ Maf�rial---- - -------- -- ._-----_.-_. iL.,— No. of compartments--------4------- ---Liquid depth---' -- ---------•--Capacity--_ lo$. ..... Disposal Field: Distance from nearest well., -W-4,---Distance from foundation------I.A-1....Distance to nearest lot line___0_0_ -____ } r p Number of lines----------�__... Length of each line.....3.G._ Width of trench. i - -------------- Type of filter material Depth of filter materil....- Total leng#h - ' " a -------------- Seepage i Pit: Distance to nearest wells.----Distance om foundation-----3-_�_0_-- Distance to nearest lot line.-_�._' _�_.__ Number of pits.------I------- ---Lining material-_ ----Size: Diamefer--3�''- -`-------Depth-----�-&. ----. l� 1 Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material-_.-----------------.-_--_-.--___-_-. �1 ❑ Size: Diameter-------------------------------------Depth----------+--------•--------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------._-----1-.-.-.--__Distance from nearest building_-_-----___--.----_---__ ❑ Distance to nearest lot line Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ ------------------------------------- ----- •-----------------------------------------------------------------------------------------------------•----------•--------•------------ ------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin --- County ordinances, State law , and rules and regulations of the San Joaquin Local Health District, t -•------------- ---------- ------------- - ----it" ------ (Signed)-- -- ------------------------------ - - (� ontractor} By:.---• - •... - - --�-- ---------- ---------- ------------------------------------- (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 Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOD 12.54