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/ y F �1 APPLICATION FOR SANITATION PERMIT Permit No. ...{!_3_��.__.. (Complete in Duplicate) Date Issued __ /------------- A plica+ion is hereby made to the Sari 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. JOB ADDRESS AND LOCATION----- ------/J�` ------------��--- ---------IG'--h e_ 7�0-�''�---------------------------------------------------------•---- Owner's Name Jn e. ----------- !!Yt-/ -/V6------------------------------------------------ ------ ---------- 'Phone.-------------------•-•----•-------- Address-------------9J �.�? / e 2 v ---------------------------------------------- --------------------------------------------------------------- Contractor s --•----• -------------------------------------- Contractor's Name-------/ ........1-,V.G---------------------- -------------- Phone-- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ Number of living units: _1___ Number of bedrooms _ Number of baths ----/-- Lot size --------X-----1_fib--------------------- Water Supply: Public system 7t 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 M 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.) Septic Tank- nce from nearest well--;.____-------_Distance from foundation_-----------------Material-_____--_____..----..._----------..------_----_. ❑ N . of compartments------------------- -----Size--------------------------------Liquid depth--------------------------Caacit -� Disposal Field: D rom nearest well-----------.- Distance from foundation------_------------Distance to nearest lot iine----------------- ❑ umbe 1 lines--------------i ----------.-Length of each line-----------------------.------.Width of trench----------------------------------- Type of filter material--------------- Df 5 pth f filter material------------_---------Total length------------------------------------------ IVO Seepage Pit: Distance to nearest well____1 a _---.'-Distance [� -rom our<dafion---..tea-_--_--Distance to nearest lot line-----ZO--___-. r of pits Numbe — _ ---------------- 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-------------------------------------------- ----------------------------------------------- ------------------------------------------------- Remodelingand/or repairing {describe)-------------------------------------- -- -------•----------------------------------------------•------------------------------------------------=------- d' ------- --------------------------------------------- -•-----••------------------•-----•------------------------------------------ •-------------•-••------------------ ---I-------------------------------------------------------- i ----------------------------------------- ----------------- --------------------------•-----------------------------------------------------------------•--------------......-- ---------•-•---------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St ws, and,rules and regulations of the San Joaquin Local Health District. Signed) [ ` `'----------- ----------------------------------------------- - -- (Owner and/or Contractor) ( 9 }•-------- By: (Title} �C - ---------------- (Plot plan, Owing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). s FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY � �r- DATE �----------- REVIEWED BY----- ---------------=------- - ----- -. ------ DATE = BUILDINGPERMIT ISSUED---------------------- --------------•-------- ---------------------------------- DATE.----------------- --------------------------------------- Alterations and/or recommendations: '--�------ - -----------•--------------------------------• ---------••--------•-----��------•-----• --•-••-------- ------------------- ----------------------- ------------------ - - - --- ��------------ ---------------------------------- ----------------------------------------•---�..-------------------------- y •-------..__'--------------------------'----------' --------- --------------- ». F --------------------------------------------------------------------------------------------------------------------------------------------------------.-------------------------------------'----------_-----------------. - _-------------_____--------------------------___------_________ ..-------_-,-------._._____--.._.---_..---_---__-._-.------..-.----.---_.--_. --_- ________________ .__-. FINAL INSPECTION BY:----- - -- ------------------------------ Date. I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOD 12-54