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Vermit No. _ ------------ (Complete d/- APPLICATION FOR SANITATION PERMIT -��--------- - (Complete in Duplicate) SCANNIVate 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. Pq 5— 1 JOB ADDRESS AND LOCATION-- -- --- ------ --- d- u25U `' Owner's Name--------- y •. -at ----------- --------- --------- --------- - ------------- Phone----4------ Address �_----- ---r __ ••---------- Contractor's Name----------------------------------- --- Phone Installation will serve: Residence R3-"Xpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: :1__._ Number of bedrooms ___') -Number of baths �_y�rLot size -------- _________________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table T6 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Clay Loam ❑ Clay [] Adobe ❑. Hardpan ❑ rt 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: Distance from nearest well--- Distance from foundation___.. __ . Matenai -- �-`� 4 No. of compartments_____.. ._..__-___.Size___ .x_gXSLiquid depth.______� f'_____Capacity.____-_ d --- Disposal Field: Distance from nearest well___-,(> _Distance from foundation___:__=1w_'_. Distance to nearest lot line_:_____. h Number of lines--------------_'y- _-----Length of each line-_____..__ _..__.-----Width of french.__--- g"_�r_—`.`r._ ________- Type of filter material --_Depth of filter matenal____:_._. ....Total length____---------------------- 0 '_.. Seepage Pit: Distance to nearest well------_---------------Distance from fou'ndation_-----------._____-.Distance to nearest lot line__r_________._. ❑ Number of pits----------------------Lining material--------..-.__---------Size: Diameter-----------------------Depth---------.--------------------_-- I Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material..........___-______________.____._- Size: Diameter-- Privy: iameter- sDenth .. � '�iquid-,Capacity ----------------gals. -c �--�-�--,. _---mow._ T. TM Privy: Distance from nearest well--.-...---- ----------------- Distance from nearest building------------------------------------------ ❑ Distance to nearest.lot line-------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)--------------------------------------------=---------------------------------.......---------------------------------------------------------------------- ------------ 4 -------- -----•-••------•---•----------•----- ---------•----------------------------- ----- - ------------------------- --------------- -----------------•----------.----- •-•---•--------------------------------- - . . -- -----------••---------•-------•----------------------------------------------•--------•-------------------------------'--------------------------------------- I hereby certify +hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules end regulations of +he San Joaquin Local Health District. (Signe �� 1 Ae-� �ll...�°---•--------------------- -- ---------•------------- ------------------ ---------------------(Owner and/or Contractor) /1' ---------------------------------------------------J. Title (Plot plan, showing size of lot, location of sys+em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - ------- ---------------------------------------- DATE------ ---/` --•--•------------ REVIEWED BY ^-' ---------- DATE -----------•----------- BUILDINGPERMIT ISSUED--------------------------------------- --------------------•-----:---------------- -------------•--.- DATE------------------------------------------------------------- Alteraflonsand/or recommendations:-------------- --- --------------------- - ---------------------------------------------------------------------------•--•------------------------------------ ------------ ---------------------------------------------------------•----------------------------------------------------------------------------------------------------------- - FINAL INSPECTION BY:. ------------------------ ------------ Date....------ r ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street- 814 Nortk "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOD 12.54