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APPLICATION FOR SANITATION PERMIT Permit No. 1 (Complete in Duplicate) Date Issued Applica-lion 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 C� --------------------------------------•-------------- JOB ADDRESS AND LOCATIO _ $ '' 4 - Owners Name------------------------------ ---- --- Phone Address--------------------------------------------------------------------------- ------ ---------------------------- . �_- Phone.---- --------------------- Contractor's Name_.------- --- �- lnstallation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel El Other ❑ I I Number of living units: __ _._ Number of bedrooms _� umber of baths _ __.__ Lot size - `� Water Supply: Public systemmmunity system C1Private ❑ Depth to Water Table __--.-__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam El Clay Loam [I Clay ❑ Adobe Q_—Hardpan ❑ I Previous Application Made: Yes El �l*I`ew Construction:"Yes'9No 1❑ TYPE OF INSTALLATION AND SPECIFICATIONS: it (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T nk: _ Distance from nearest well______ _______Distance from foundation--------------------Materiai-------____.---_________________---_-___.___- No. of compartments------- ---- ------- Size-----•----------- Liquid depth - Capacity ,� 1 �^ (J QDistance from foundati 0_- - Distance to nearest lot line____.c�-- - + Disposal Fiel Distance from nearest well. - _ i�' Length of each line______ -- Width of trench.____ Number of lines,_�5_ --- g F Ai •� 1 ' t_De Depth of filter material-------- Total length_________:/.Type of filter material T- __ p l :.t Seepage Pit: °, Distance to nearest well______________________Distance from foundation__-._____-.___-____.Distance to nearest lot ine_-___._________._ i. e - ; ` Size: Diameter.-----------._._ Depth--------------------------- ❑ Lining material--------------------- - - Numbsr of pits- ---'.---�------- --- , I #Cesspool: , Distance from ne=t from foundation___.__________.._-.Linin material-----------------------------------__. ❑ I*SIZe:-fDidmeters Depth-- -------------------- ----- --- i Capacity 9 s. -----= ---------- Liquid .. al jJF ---------------Distance f Privy: Distance romnearest building-----____-______------------------------- �- from nearest well_._..-_---------------------- -- ❑ ------------------------------------------------- Distance to nearest lot line--------- -------- -------------•------ ---------------- Remodeling _ and/or repairing (desc'ri4�e�------------------------------------ ------ i i r - _ _ _ -----------------------------=--------------------- - - -- -- __� .. --------------------- ------------ ------------- --•- 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. ----- ------------------------------------ . _(Owner and/or Contractor` _'r;1 -- - -- - ---------------- ----- ----------------- ------------------ ---------- (Title) Y= (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----- .----�.------................ --------------- DATE----------✓-- ---- --- --------=---- REVIEWED BY :. ---------- ---------------------------------------- DATE---------------------------------------•----------------- DATE------------------------------------------------------------- BUILDING PERMIT ISSUED-------------------------------------------------- Altera#ions and/or recommendations---- --- ------ ------=-------------------------- -----------------------------------------------------------•-----------------•-----•--------------- --------------------------- i €per -------•- --------------------------------------- INAL INSPECTION BY:____...._ r �-�'Z�--��-�------- - -- -- ----- F - ------------------- Date 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Es-9-2M 145446 ATWOUD 12-54