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APPLICATION FOR SANITATION PERMIT Permit No. ....... (Complete in Duplicate) Date Issued __..___- _____�_J_ Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 49. JOB ADDRESS AN LOCATION _ .___�__-_ -------------------- --- OWner's Name- .� Phone ---- --------- ---- - Address_.... .� = --•-------•- f Contractor's Name------- _ ��i---------- --------•_-_-------- ---------------:------------ Phon - `R OU-1-- Contractor's Installation will serve: Residence A—WP—a"rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ___ Number of bedrooms-_-_ Number of baths __.._ Lot size _ _-_-- 7_ .__r____________________ Wafter Supply: Public system �-o'mmunity system ❑ Private ❑ Depth to Water Table -Oft- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: Yes ❑ No g--Igew Construction: Yes ❑ No 4+__ ` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptiac a k- Distance from nearest well---------- ------Distance from foundation--------------------Material----------------------..--.---------------------. i No. of compartments ________________Size--------------------------------Liquid depth--------- ---------------Capacity isposal Field. Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line__________-___.__ Number of lines-----------------------------------Length of each line--------.-------------------.-.Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material--------------- ------Total length------------------------------------------ 7-1-15 __--___-_-_____________________ _____ �,} Seepage Pit: Distance to nearest wel!__ _ . ____.__ ____Distance m foundation____ __ Distance to nearest lot line----�_._ Number of pits.__-I-__-----------Lining material___bFAe _ _._Size: Diameter_2.3_f___t r ._..____Deptn._.plfd_______________.__ Cesspool:. Distance from nearest well-----------------Distance from foundation--------------------Lining material-_______._._____._________._______._. ❑ Size: Diameter------------------------ ------------Depth----------------------- ------Liquid Capacity- --------------------------gals. Privy: Distance from inearest well__--------_-----_------_-----_--------------------Distance from nearest building-------------------------------------- ❑ Distance to nearest lot lihe------------------------------ --------------------------------------- ------- ---------------------- i 'S Remodelingand/or repairing (describe)------------------ - - ---------------- ---------------•-----•---------------••--------------------------------------------------------------------------- ----------------•-•--------•--•--•----•-------------------i------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- 3 l ------------------------------------------ -------------• •------------•---- •--------------------------------------------------------------------•------------------------------------------------------------- --------- 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) ----------- ------ --------------------------------------------------------------N6"N_"dAG_Contracforj By—. ---------------------- ------ - ---------------------- *! .. ......t ` ------Title ------- ----------------------- (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------- ---- -------- --- --------------------- -y--,�-- --- - --- ,� s, ------------- DATE-------------------------%6_6------------------------- - REVIEWED BY--------------------------------------------• -- ----------------------- ----•------.---------------------------------- DATE-------------------------------------------- --------------- BUILDINGPERMIT ISSUED-----------=---------------------- ------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations------------------------------ ------ ------------------------------------•--------------•-----•----------------•----------------------- •----------- - -- -- - ---- -- -•--------------------------------------------- --------•-------------------------- _______________ ...... __. _...._.______...______ _._ _ --.. .. _..__..k....____......_ ____..___..-___..__.______.._________________.----------------------------------------------------- _ ________ _______ 1 1-1----------------------------------------------------•---------------------------- -----------------------------------------------'__----------•-----------------_•--__----------- . =a �^ FINAL INSPECTION' BY: ----------------------- ------ Date- ------ a---------------------------------•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfroof , 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 145gg6 ATWOOD 12-54