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M� 1 yam ` ' APPLICATION FOR SANITATION PERMIT Permit No. . � (Complete;in Duplicate) III Date Issued ---- ------------ ---- Applica}ion is hereby made to the Sen 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� ` JOB ADDRESS AND LOCATION__, ---/Z-••-----?2e'------- ------------------------••---------------•---------------------------- Owner'sNa •-- � � ------------------------------------------ --------------------------------------------- Phone. _--- �1� Address---. 44---- ------- ----- Contractor's Name----------------------- ---------- - -- - --- �- ._ __.---__ Phone -------------S�Z� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Number of living units: j-___ Number of bedrooms 3 Number of baths _/___ Lot size , Water Supply: Public system ❑ Community system ❑ Private;< Depth to Water Table l±Zffi. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ CI oam p Clay ❑ Adobeardpan ❑ s Previous Application Made: Yes ❑ NoNew Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T Distance from nearest well-�4 -. Distance from foundation ------MateriaL_ �___-__ [ •. .� No. of compartments__.__.C1�-___._..._ Size_.�..h._.��_.___._..Liquid depth__��------------Capacity..._Ct__----d,��_ � Dis oral a d: Distance from nearest well-_.__6�_ Distance from foundation___YU____-__.Distance to nearest of line___________`s P , , Number of lines________ ______ ___._.--_-___Length of 'each line----/9�__ --------._.Width of trench__}�'`�_--._--_._ Type of filter materialSc___o_Gi -------Depth of filter material-------- _..Total length;-_-/ '---________-___--__._ � Seepage Pit: Distance to nearest well----------------------Distance from foundation-------.. ..------.Distance to nearest lot line__.__.___________ ❑ Number of pits----------------------Lining materia;-----------------------Size: Diameter-----------------------Dept h-------------_------------------- Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material-------------------------------------- - -j I ❑ Size: Diameter------ ------------------------------Depth------.:---------------------------------------------Liquid Capacity-- -----------------------gals. 1 Privy: Distance from nearest well-------------------------____---------------------Distance from nearest building_________.__.__________.._-_-._ ❑ Distance to nearest lot line---------------------------------------------------------------------------------•-•------•------------------------ " t Remodeling and/or repairing (describe):-----------------------------------------------------------------------------------------....... --------•-••-----------•-------------------------------- ------------------------••---•-•--------------•------------------------------------ ------------------•----------•-------•-------- ------ - I -------------------------------••------------------------------------------------••--------------------•-----•--•----------.-----------------•---------------•----------------------------.-..-------------------------------- ---------------------------------------------------•-------------------------------------------•--------..------------------------•-----------------------•--------------•-------••---------------------- ------------ I --•-------I here 5t ify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinan, to aws, anO ru s and regulations of the San Joaquin Local Health District. �� (Signed) -�.- -!_____ ______________ P-lowner and/or Con+ract6r By:--------------------�- - `�`"-- > .r ---------------------------------------------ITitle) "G+ [Plot plan, showing sife of lot, location of Sys+e in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY p APPLICATION ACCEPTED BY---- -----I DATE Q REVIEREVIEWED BY----------- x WED -------------------------------------- BUILDING PERMIT ISSUED------------- -------- - - ------------------------------------------------------------------- DATE-------------•--- - , - ---------------------------------- Alterations and/or recommendations: -----------------------------•-----•------------------------------------•-••------------------------------------•--•- --------------------------•-- ------•---------------------------------------------- ------ ------------ ----------------------------------------------------------------------- ------ -�}} FINALINSPECTION BY:------ ------------------------------- Date.-----. .--------------------------------- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfraef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California En--9-2M 145446 ATWOOD 12.54