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APPLICATION FOR SANITATION PERMIT Permit No. .._ -. ._L.. (Complete in Duplicate) � r � Date Issued ._-_I 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 'AND, LoOCATIO ...../.671.-�-------- Owner's Name.� � ----- --- - --------------------------------------------------------------- Phone-----------------------•---• - Address-------- -.-A `---------- ----------- -----------------------------------------------------------------------------------------------------••----•---•--------------------------- Cont'ractor's Name----- ' - .- ------------------ Phone . `"-�- f- Installation.will serve: Residencearment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _Z_ Number of bedrooms _2'- Number of baths __2._. Lot size -.__---4---- _______________ Water Supply: Public system ommunity system ❑ Private ❑ Depth to Water Tables...- ft- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: Yes ❑ No a]..wNew Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) E Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material ----________-___-..----.--.-.._-______------.--. No. of compartments------------ ------ ------Size-- _------------------------Liquid depth----------------- --------Capacity-•--------------------- i Dispo al Fiel : Distance from nearest well -Distance from foundation--------------------Distance to nearest lot line----------------- f ,t! "� Number of lines-----------------------------------Length of each-line---------------._--_•.-___....Width of trench----------------------------------- / Type of filter material-_---------------------Depth of f;l#ermater;a[----------_---_------Total length------------------------------------------ Seepage Pit: Distance to nearest welio-?_4+--�------Distance om fou dation-----/ ---__-.--.Distance to nearest lot line--_�a__`__.. 16— Number of pits-------I------- ---_Lining material- ._ _. Size: Diameter --------------Depth. r w .. - r p �"�jf ------------------- Cesspool: Distance from nearest well-----------------Distance from foundation._.__._._._._______.Lining material--.-_----_.--___._-._------.---_----_. ❑ Size: Diameter Depth- I'--" ---------------------------------Liquid Capacity----------------------------gals. 'Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ P ❑ Distance to-nearest lot line------------------------- ---•-----------------------------------------------------------------------•-------------------------------------- } Remodeling and/or repairing Idescr;ire)---------------------------- 1 --�"-------------------------------------------------------------------------------------------------------------------- { -------------------------------------------------------------•--------------------•-----------------------------------•-------•----------------------------------------------------------------- ----------------------------- I hereby certify that I have prepared this application and tha+ the work will be done in accordance with San Joaquin County x ordinances, $fate laws, and rules and regulations of the San Joaquin Local Health District. r . (Signed -------- --- -- --------------------- ------------------------------ --- --- --------- ------Owner and/or Contractor By:-------. ----------- ---------- --------------------------------------------- Ti ---------------------------------------------------.-.. {- (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------------- _ .S.S----------------- US REVIEWEDBY-------------------------------- -----------------------------------------------------------------------------------•-------. DATE-------------- ------ --••- ---------------------- BUILDINGPERMIT ISSUED------------------------------------------------------ -------------•----------------------- --------- DATE------ -------------•----------- Alterations and/or recommendations:---------------------- ----------------------------...----•--------------------•-•------•------•-------------..--•----------•--....---------------------------- --- �:--- .---- ::: ------------------------------------------------------------------------------------------------------------- --------------------------- -------------------------------I---------------------------------------------------------------------------------------------------------- --- --- ---------------------------•---------- I FINAL INSPECTION BY: _.-.. 1 -------------------------------- Date_----J�.---- --- ---- 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-9-2M 145446 ATWOOD 12-54