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y 'APPLICATION FOR SANITATION PERMIT Permit No. _19.3.. z _- (Complete in Duplicate) Date Issued __�__f�.�__ Applica�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. JOS ADDRESS AND.LOCATION----- 70 -------------- Owner's Name-----------------•------------------ -------- -- ------ Phone------------------------------------- Address------------------------------------------ J ----------- --------- Phne -r-- Contractor's Name , -----_ - -�-- ----------------- - --- - - ------- ' oT_l'./-/` --------- Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 4 Number of living units: __/___ Number of bedrooms _member of baths --_ Lot size ------ -------__________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. _-Ir Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ .Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob�ardpan ❑ Previous Application Made: Yes o ❑ New Construction: Yessj;l_ E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) a � Ss ' Tank: Distance from nearest well------------------Distance"from foundation--------------------Material ___----_----------------_____ o. of compartments------ --------------Size--------------------------------Liquid depth------- '__Capacity----------------------- „ Disposal Field,: Distance from nearest well N�'�13istan.ce from foundation____�O __._.Distance to nearest lot line.__.._ - r , Number of lines------------t{__.______________._Length of each line___'.` _. ----------Width of french------- _111--------------- Type ______________Type of filter material__ : .:.,Depth of filter material-------PS.!!___Total length------------ ______ ___________ Seepage Pit: Distance to nearest well__, -Distance from foundation____ r� _ � ------ Distance to nearest lot Number of pits.__.____..----------Lining materiak _.Size: Diameter---- ............Depth------- ______._______ f Cesspool: Distance from nearest well-----------------Distance from foundation.___------ ....._..Lining material__:.__.. __.-_-..____---.___-_____. O Size. Diameter------------------------ ----------------- -- ----------- Depth---------------------- -----------------------.Liquid Capacity gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.___..______._______________________._. ❑ Distance to nearest lot line--------- ------- ----------------------------------------------- -------------------------------------------------------------------- Remodeling and/or repairing �clescribe):------------------- `'`.{ ---------- ----- ------------_------------------------------•_----------•--.---- -------------------------••----------------------------------- ---------••-------------------------------------------------------------------------------------------------------------------•---- ---------------------- I ----------------•---= --------------------------•------ --------------------------------•--- a -------------------------------------- -------- --------- ---- ---------------------------•-----------------------------------------•------------------------------------••-------------------------------- ------------ 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 +he San Joaquin Local Health District. I By:. - tile} wn and or Contractor [Signed}. ' [Plot plan, showing size f lot, location of system in'relation to wells, buildings, a+c., can be placed on reverse side). l FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED By _ ------------------------- ---- ---------------------------------------------------------- DATE.,^-_-----------------------------•------------------- - ---`--F'---- ------------------------------- ------------------ REVIEWED BY------------------ ----- - ---------------------------. DATE'7:'*__.----------------•-•--------------------------------. BUILDINGPERMIT ISSUED----------------------------------- ------------------------------------------------------------- DATE----- ------------ Alterationsand/or recommendations----------- -------- ------------------ --------------------------------------------------------- ------------------------------------------------ � . --•--•..................•-•------------------ ------ ---------------- •------ ----- ----------------- •.--------- --------------- .......__....... ----------------------------.---..--------------•---- ---------------------------------------- --- --- ---- ------------ -- -------------------------------------•-- „i Date--------d.- ----------------------------------- FINAL INSPECTION B ,' -----�-- ---•-- - - - -------------- -�l �---------- 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