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APPLICATION FOR SANITATION �� N I'ERMlT�. � Permit No, .._A • (Complete in Duplicate) 3 Date issued --- �v1- Application 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. i 9 JOB ADDRESS AND LOCATION__---- Owner's Name-_ ---. --•----- Address----------••- - Phone-----•--- --- -•-- --- - �1�—_-- ----•------------- � ---- --------------•------------------------ -------------•--------------••-----------------•---•--------• ------------------ Contractor's Name------ __.._ __ Phone __,......-----•------•---- - • • ------------------------------------ ------- ❑ ❑ Other --------------- Installation will serve: 'Residence [� Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Number of living units: __./___ Number of bedrooms��. Number of baths 1-_a,_ Lot size . ------X-�. _.. = Water Supply: Public system ❑ Community system ❑ Private A. Depth to Water Table Character of soil to a depth of 3 feet: Sand ElGravel F] Sandy Loam [) Clay Loam E] Clay E) Adobe 9— Hardpan ❑ Previous Application Made: Yes ElNo [sem New Construction: Yes 0 No � r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: istance from nearest well__;______________Distance from foundation-------------------Material__-________-_,_.___._____._.___-•_ ❑ - -- --. of compartments --Size--------------------------------Liquid depth-----------...------------Capacity--------------------- - rr Disposal Field: Distance from nearest_ well___ ._ __....Distance from foundation_ -------Distance to nearest lot line--- -d------ Type ber of lines__________ __ ___ __ Length of each line_-______ C�_ _._ A iy Width of trench______ --_---_--.-_ e or filter material__./,-____$,R_--Depth of filter material__---__ Total length----------- _ ____________+ -•--•-- Seepage Pit:, Distance to nea est well_____._.___-_____.___Distance from foundation----------_---------Distance to nearest lot line_______---._____ ❑ Number of pits._!------------------Lining material------_.-______._.-__Size: Diameter---------- _ Depth r --------------Cesspool: .. \ Distance from nearest well_________________Distance from foundation---____------------.Lining material-------- El ------ ----------- Size: Diameter Depth Li Liquid Capacity ----------gals. Privy:' Distance from nearest well---------_---------------_--------------------._Distance from nearest building \ ❑ Distance to nearest lot line' ___________________---___--.--- ----------------------------- Remodeling and/or repairing ________ __._._________..__________ --------------------- _____________---------------- _------------------- ___________________________________________________ ___ ------------------------ --------------------_------------------------------------------_______________________________________________________________________________________________________________________________________________________________ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e s and rules and regulations of the San Joaquin Local Health District. _ r � (Signed}_ ----------- ---------- ------ --� . -----------------(Owner and/or Contractor) By:.--� 2 I �.-_ -----------------------------Title--- (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.(Q ---------_----------- DATE_--------- REVIEWED ---ED -- --- `--. ----------------- ---------------- ------------- BUILDING PERMIT DATE_.. ----------------------- T ISS SUED---------- - - - --------------- ----- DATE �----------------- Alterations and/or recommendations:. ..............:.... . .. :: ----------------------------------------------------------------------------------------------------------------- 1 ------- •-------------- -------•----- FINAL INSPECTION BY:..----- .4-- ------------------------ -- ---------- Date.... # SAN JOAQUIN LOCAL HEALTH DISTRICT r 130 South American Sfreet 300 West Oak Streete 132 Sycamore Street 814 Nor" "C" Sfreef �,- �- Stockton, California Lodi, California Manteca, California Tracy, California ES-^9-yM 145446 ATWOOD ,2.5;