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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date IssuedJ- Applica-lion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descr ed, This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATIO ,_ �° Owner's Name r 4 --------------------•----------------------- ------------------ ---------- Phone,• Address --------- --------------� Contractor's Name...--------�,�� ` -------------------------------------- ------ Phone----------- --- Installation will serve: Residence g3r--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __l__ Number of bedrooms -_ Number of baths __Zt. Lot size __-- ---- ------------------•---------- Water Supply: Public system ❑ Community system ❑ Private ` [ "`Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe b—l'ilydpan ❑ Previous Application Made: Yes ❑ No Pq"'`-New Construction: Yes ❑ No Ate•' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sepis „Tank: Distance from nearest we}i--------------_Distance from foundation--------------------Material _______________________________________-__-____. Y,t• sl No. of compartments------------- -----------Size--------------------------------Liquid depth------------------ ------Capacity----------------------- Dis s�,F�ld: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- Number I Number of lines------------------ _--------------Length of each line___________.._...___._._ Width of trench-------------------- ype of filter material-------------------------Depth of filter material----.---------_--..___-Total length__-_-______-_____________ Seepag Pit: Distance to nearest well-_A �_ Distance from pfoundption___IK-e----.D' t n`e,to nearest lot line_--!!�---- Number of pits--------/__.__---_Lining mate rial_�_.__� rze: Diameter---.__-�-.._ ______._ .._Depth----- -------------------- Cesspool: -�-- ------.. 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 rules and regulations of the San Joaquin Local Health District. o a ______---_ {Signed) ----------- -- ontract ) •------------_-------- ' BY --- - (Title) � ---- or [Piot plan, showing size of lot, location of system in relafi to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------- ---- ----- - ----------------------- ---------------------------------------- DATE------ q�5 REVIEWED BY ------------ ------------------------- - DATE f, --- h ---------------------- UILDING PERMIT ISSUED------------------ -=----------------------------------------- ------•--•----------•--------------- DATE---------- Alterations and/or recommendations:_ - -------- - ------ - •--------•----- ---------------------- -tir - - - ---- .----- --------------------------------------------------------------- FINAL INSPECTION BY:....___._ -------- ------------- Date--2� }T 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 E5-9-2M 145446 ATWOOD 12-54