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,-pip APPLICATION FOR SANITATION PERMIT Permit No- -----7............... <br /> (Complete in Duplicate) Date IssuedL!'Z <br /> ----- ---------------- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance'with County Ordinance No. 549. <br /> JOB ADDRESS AND LOC- AT N....---`•----?�'�...... . ,�---�_--- --..j-..-.------------------- ---------• -•------------------------------------------------- <br /> -------------- <br /> Owner's Name - ..... � -�/fes'--t-- Phone <br /> Address-----------•--•-----------•----- --..... ---------------------------------------------•--------•---------•------------------------------------------------------------------- <br /> Contractor's Name------------ >��"Y Phone <br /> Installation will serve: Residence Ri�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel p Other ❑ <br /> Number of living units: -/---- Number of bedrooms -A---- Number of bath4--1-- Lot size --- � 1-Z-49--- I <br /> Water Supply: Public system ❑ Community system ElPrivate 171 /",Depth to Water Table _ nt. I <br /> l <br /> Character of soil to a depth of 3 feet: Sand ❑ . Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe Ig--Hardpan 1 h <br /> Previous Application Made: Yes ❑ -No ?�­ New Construction: Yes g Now— 'V <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well................:Distance from foundation_-_---------------Mater.iai---------..--------------------------------------- <br /> ❑ No. of compartments--------------------------Size---- ------Liquid depth-------------------------Capacity------------------- <br /> Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- <br /> ❑ Number of lines-----------------------------------Length of each line-------._---------------------Width of trench---..-------.---------.-------.--- <br /> Type of filter material--------_.______________Depth of filter material----.-------------:----Total length--------------------------------.___----_- <br /> Seepage Pit: Distance to nearest Distance from foun ation--RP------------Distance to nearest lot line---- <br /> Number of pits-- ------------ Lining _material- - *----. xe: Diameter- -------------Depth----o ------------------- <br /> Cesspool: Distance from nearest well-------- ------Distance from.foundation---- .------.-----..Lining material----_---------.----.----.----_------. <br /> Size: Diameter----==-------------------------------Depth------- ------------------------------ --------------Liquid Capacity------------------------_-gals, <br /> Privy: Distance from nearest well-----------------------------_----- Distance from nearest building--------------------._._.-----_-_------- <br /> ❑ _ Distance to nearest lot Iine------------------------------------------------------------------I----•---------------------------------------------------------------------- <br /> Remodeling and/or repairing (descrif e):---------------------- ----------------------------------- ------------------------------------------•-------- <br /> 1 <br /> i. <br /> -------•---------------------------------•----------------------------•--------------•----------------•------- ------------------------ -- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health-District. <br /> (Signed)------------- (Gwnepqmd�or Contractor) <br /> By:--------------------------------- ------ ----- G ---------------------------------------------(Title}._.. -------------------- <br /> (Piot plan, showing size of lot, ! tion of system in relation to wells, buildings, etc., can be placed on revers side}. <br /> F FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__ _. 1 DATE - --- -- <br /> ----- ------------------------------------------ <br /> REVIEWEDBY------------------------------_,, _ ------------------------------------ DATE----,.-- ------------------------------------------------- <br /> BUILDING PERMIT ISSUED. --------------------------------------------- -----. DATE--. ----j6- - - <br /> Alterations and/or recommendations:---------------------------- - <br /> ------------------------------------------- ------ <br /> C .. --------------- <br /> -----------------•-- ------------------------------------ <br /> -.- <br /> a-� - -------- - --•----------------------•---------- -------------• -.--- - ...-.------ <br /> -------------- <br /> ------------- ------------------------ -- -- ---•----.----.- <br /> -------------------------------------------------------------------- <br /> ----------------- <br /> -- --- - <br /> FINAL INSPECTION BY:.-- ------ Date--...-. <br /> � <br /> ISAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9--2M 145446 ATWOOD 12-54 <br />