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APPLIGAP!)ION OR SANITATION PERMIT Permit No. ..._------------------- (Complete in Duplicate) g/ 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., AT his apjRlicat'cn is made irl complian th �,ounty Ordinance No. 549. JOB ADDRESS AN LOCA N_'T11--. '.,r C .. + =------------------------------------------- -------- Owner's Name--------- _ - ----._-_-_ ---------------------------------- - -------------------------------------------------------------- Phone_ jt- 'Address---------------------- -.t..�------:--C7--"-r .T - ------ - ----------------------------------------------- Contractor's Name `--'------- -------------------------------------r-- -------------- ------------------------------------ ---•--- PhoneA-....3-'�7 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motefl Other ❑ Number of living units: ---t--- Number of bedrooms -. Number of baths ---I... Lot size - -(------------------_------------------------------------------------- Water Supply: Public system ❑ Community system ❑ Private ]epth to Water Table 4 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ 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 Ta Distance from nearest well________________Distance from foundation---------------_-_.Material-_-----___.-----__----.._--_-_----------------. No. of compartments-------------- -------- Size---------------------------------Liquid depth--------------- - __Capacity Disposal I Distance from nearest well-----------------Distance from foundation- -.-------.---.Distance to nearest lot line----------------- ' �&„ Number of lines-----------------------------------Length of each line----------------------:------.Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepag it: Distance to nearest well---4. _ '-___.--Distance from foundation Distance to nearest lot line- Number i�_ Ca. I Number of pits.--Z-___-____---Lining materlal._� - .-----.--.Size: Diameter------- -------Depth...../.4 -------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--__--_-----__--__-.------------- ---- Depth__.----_.----.-----__-----_.-.- Liquid Capacity----------------------------gals. Size: Diameter---------------- tOw --Privy: Distance from nearest well....--.--. - - -------------- __ ___._Distance from nearest . building.---.---_----------__-.-.-__-___--_-_. ❑ Distance to nearest lot line----------------------------- Remodeling an d/ re airing describe]:_-._----_.__----------- -----` L�L - --- --------------------- ------------- L 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. (Signed) . --„---- --•-------.-_-.---------------- -------- - ----- ------------------------------------------------- ------ -Owner and/or Contractor) ------� a------------------------- -- -----------------------------------------{Title) t -- ----------- ---------------- .......... ------- (plot plan, showing size lot. location of system in relation to wells, buildings, etc., can be placed on reverse side Q� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY=----------------------- ---------------------------------- DATE------ --------------- ----------- REVIEWED SY = DATE, --- .--- ---�-_`�- ..fi ... BUILDING PERMIT ISSUED ------ f'� E- - DATE Alterations and/or ree mm dations:.------ --------------- ------------ -------------------------------•-----------------------------------------------------------------•----------- 4 ---:- J -- . . -------- --------- ..:�-`------------------------------------------------------- .-.. - --------------- ---------- --- = ` FINAL INSPECTION BY: ��_ = ------------------- Date.--- ;7--' -------------------- { ' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9 145446 ATWOOD