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APPLICATION FOR SANITATION PERMIT Permit No. ._Y __-_.�__�_ (Complete in Duplicate) !�, I ] ` Date Issued ----------•----___("__ 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, JOB ADDRESS AD LOCATION --moi"- ------- ,N Owner's Name - _. ----- 44, '''F"''" k :z-rv►'�'¢X__ Phone0 lj fo Address-----•-•-- c-�------ --------------------=-----------•------------------------------------------------------- -----------•----------------------------- Contractor's Name-----c -'w---t*--------- --------- - ------ = Phone R Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer ICourt ❑ Motel `❑ Other ❑ Number of living units: __ ____ Number of bedrooms .3-- Number of baths _--_____ Lot size r _t.1__ _ _______________________-___ Water Supply: Public system) Community system El Private [-] Depth to Water Table -------- ft. 7 Character of soil.to a depth of 3 eet! Sand ElGravel E] Sandy Loam [j Clay Clay Loam Clay E] Ado E Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes ❑ No IK + TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank; Distance from nearest well------------------Distance from foundation--------------------Material--------------------------------.-- ---:______- ❑ No. of compartm ants---------- ------------Size--------------------------------Liquid depth-------,= ----------Capacity----- ----------------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------.Distance to nearest lot line_______________. Number of lines-----------------------------------Length of each line------------------------------.Width of trench--------------------------------•'- 'J""'" , Type of filter material------_-----------------Depth of filter material------------ ''Total length----------------------------=------------- Seeps Pit: Distance to nearest well----------------------Distance from foundation--------- ------ Distance to nearest lot line----------------- � Number of pits---- ----------------Lining material-----------------------Size: Diameter-----------------------Depth____._.______________----------- 1 Cesspool: Distance from nearest well-__--------------Distance from foundation---._.__:----------.Lining:material-----------------____________________ ElSize: Diameter-.. #--- -----------------------------Depth-- --------------------------------------------------Liquid Capacity---------------- -------gals. "V 11 Privy: Distance tram nearest well- -------- ----------------------------------....Distance from nearest building-----------=----------------------------- El --------••------- ------❑ Distance to nearest lot li ---------------------------- -------------------•------------•-• ---- ----------------------------••----------------------------------- Re eling and/ -rep firing {decri4�e�: ---- - - ----- --- ------- J4, -- � � . A---- - ` ------------- ---•------ -------------------- ------------------------------------ _ • ________________________________________________________________________________________________. --_-..._---_____-_____-____-----_--___-____--_-____-______-_-__-_-_____-____--__---____ I hereby cer4ify 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. x -------------------I_ ---- ----------__.------------------ ------Owner and or Contractor (Signed)------------ ----------•----- - -- �--------------------- -- - --- - ---------------------- - { / ) BY� - ------- - - ------------------ ---------------------------------•------------(Title)--------------------------------------------- -------------- By�Z plan, showing ple of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). y ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- '--=----•------------- ------- ------------- ---------------------------------------- DATE------- - -------- - - - --------------------------- REVIEWEDBY---------------------------------- - ------ DATE--- {-------------- --------------------------- BUILDING PERMIT ISSUED--------------------(\1- ------------------------------------- •-- ---------------------- DATE_------ - --------------------------------....__.Alterations artd/or recommendations: T ----------------------------------------------------- ------------- ---•----------------- ------------------------------------------------- --------------------- --------•---------------------------•----------------------------••----•--------•----•---•------•------•------------ ----------------------- -------- - ------ - ---------------------------------------------------------=----------------------- ------------------------•------------------------------------------------------------------ FINAL INSPECTION BY:. � Date c L i _------------ 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 145446 ATWOOD