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APPLICATION FOR SANITATION PERMIT Permit No. .__Q.-5�. __ (Complete in Duplicate) L Date Issued _ I`a,/,_--- 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. 544. JOB ADRESS AND LOCA fON - ,.,c ,, ,_._- --"' Owner's Name------ ---------------------r•------ - - ------------------ -------- ... Phon , -- f�- '_ __.•__. ---------------------- Address.--- ©'-•-• �r"'~r . --------------------------•-----------•---------------------• ----------• -- --------------------------•- -------•--- - Contractor's Name_____ •• -- ------------------------------- ---a--------------- - ------------------------ Phone Installation will serve: Residence Apartment House ❑ Commercial . Trailer Court ❑ Motel. ❑ Other ❑ Number of living units: -1------ Number of bedrooms A---- Number of baths v� p ------- Lot size .---90-_tA.�,� Water Supply: Public system ❑ Community system ❑ PrivateZ Depth to Water Table e-L t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam PV Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 'M • New Construction: Yes JM 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---470 '--Distance from foundation----4d'_------Material No. of compartments-------9----------------Size__1 t---`-3- -`r _--- -- -- - ------•---Liquid d � epth--- ----- --------- P y� Ca aeit -- Disposal Field: Distance from nearest well. Distance p --_ Distance from foundation---/0-'_-- . Distance to nearest lot line____��---- Number of lines,------_-._-_.._ _-_-__-__ Len th of each lin o -- . Length X �'_!�_..Width of french..-Ay- ----------- Type of filter material.f__}_, Depth of filter material---/?---*............Total length:_.__ _---------------------------- Seepage Pit: Distance to nearest well ------_---Distance from foundation____--------------------- Distance to nearest lot line_-_____-___.___._ ❑ Number of pits-------------------_-Lining material-----------------------Size: Diameter------------ Depth Cesspool- Distance from nearest well...... _____� Distance from foundation-------...-_-__.__.Lining material__.._-__.._.__._____-__ _ --------------. ❑ Size: Diameter . ----De th-=-------------------------•- -------- -------------Liquid Capacity----------------------- p ---gals. Privy: Distance from nearest well_-------------------------- ------------Distance from nearest buildin ❑ _ 9 --- Distance to nearest lof I ne....___- - - --� , - - - t Remodeling and/or repairing (describe):___________________ v ----- -------------- ------ --------------------•--------------------------------------------------------------------•-----------------•------------------------------------•------------------ ----------- 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. r (Signed)------- -------(Owner and/or Contractor) By: - (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-----REVIEWED BY ----------------------------------------------------------- DATE---- '. -------- ----------- ----------------------------------------------------------- DATE------------------------------------------------------------- Alterations - - UILDING PERMIT ISSUED----------------------------- --- ------------------ -------------------------------•-- ---------._ DATE-------•---------------------- - ------------------------ A fierations and/or recommendations:_---- ------- -------------- -- FINAL INSPECTION BY: -.. - :-h: ----------- Date.. � Q- S� -4 - ----- 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