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I APPLICATION FOR SANITATION PERMIT Permit No. .......?Z/ (Complete in Duplicate) Date Issued Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install hee work heein descr bed. This apciliccation is made in with&4y Ordinance No, 549. JOB ADDRESS AND LOCATION__ ��+_._ � ! '' f �- ----- ---------- - ------ --------------- Owner's Name' -------�--....`�'✓- �`"' = Phone_ Address -------- 2 / �� ` -,� 49 --------------- , f Contractor's Name ---•----------• •- -----:---- Phone-------•- _ -------- - �---•----------------•------------ Installation will serve: Residence A Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J----- Number of bedrooms _ __._ Number of baths _ _ Lot size _-- --------------------------------- Water Supply: Public system ❑ Community system ❑ Private ©" Depth to Water Table " ft, t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ 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.) ;- _ yFq Septic Tank: _Distance from nearest we31 -------Distance from-foundation-J __7777Material-__________________ No. of compartments Liquid - p --- _� TH� , P "� -------- - Size-- •-�--.��.--�------•Li uid de th._.__`�----- - --- Capacityf�.� � Disposal Field: Distance from nearest well-;.�-------- -Distance from foundafion_�d_ -_ -_ ---Distance to nearest lot line._L_______..___ 9L Number of lines--------I-......---- -- ---�-�-e--Length of each line-----(0 t--- Width of trench--- - -!---------- Type of filter material_____-,! _ 9epth of filter materialTo}al length---.-/--? Seepage Pit: Distance to nearest well-_--------------------Distance from foundation--------------------Distance to nearest lot line_.--_-_-_______- ' ❑ 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 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 laws, and rule and regulations of the San Joaquin Local Health District, (Signed).... � ~, { ✓1- --------------------- -------(Owner and/or Contractor) B � `� -� _ Y•--•-----••--- 4 -- ='r Title lan° showin lei _ : �. ( )--•------- ------------------------------------ ------------- - ( p maize-of-fot;Ybtafi n-of system-in=relation=to weHs,`buildings,etc:;'cane-placed-on=t.everse-side).`_=-^¢' A� FORvyDEPARTIv_ENT USE ONLY APPLICATION ACCEPTED BY---- f --------- --------------------------------- ----- DATE -------------------- REVIEWED BY ------- ------------- ------ DATE ----------------------------------- UILDING PERMIT ISSUED----------- ------ DATE ------------------------------------------------------------- Alterations and/or recommendations:-:----------------------- -------•---------••--------•----------•-----------•-------------------------- ---------- FINAL INSPECTION BY----------------- ---_ _____-_ Date -�j l v D--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ; 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California t Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOD 52-5a '