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APPLICATION FOR SANITATION PERMIT Permit No. _21__'-'1-.'."-....... <br /> (Complete in Duplicate) pate Issued ----------------­----q.- im <br /> Applica;-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with ounty Ordinance No. 549. <br /> JOB ADDRESS AND LOC ATIO - __-- _ _ d' <br /> Owner's Name------- --- R --------- - --------------- ��------ <br /> -• --- - ----------------------------------------- - - - ------------- - -. Phone------------- •-•---------•--- <br /> Address------Z 1,!A..._--------Q-------------------•---- <br /> Contractor's Name 1 Phone - �'.5.� <br /> Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ <br /> Z ,.;Number of living units: _____--- Number of bedrooms -------_ Number of baths --i----_ Lot size -_-,_--- --.0:-. �---------------------- <br /> Water Supply: Public system ,Community system ❑ Private ❑ Depth to Water Table ; ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No Q-l"New Construction: Yes 1�'No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if ublic sewer is available within 200 feet.) <br /> Septic nk: Distance from nearest well--.- -N-Q- Distan a from fou dation--1-I�-.-.-----_.Material- ___ ------------ <br /> - - <br /> No. of compartments____--.7--' ----..... <br /> ----size_ 1 ' k4�-If��-Liquid depth-3_�4N-d -----Capacity----- <br /> `� <br /> Dispos Field: Distance from nearest well... t .Q:--Distance from foundation---1_Q------------Distance to nearest lot line_-�--------- <br /> Number of lines--------1-------------------------_Length of each line----->–..O-----------------Width of trench-,_Z_*--------------------- <br /> Type of filter material__�•4-tk,.___---.--Depth of filter. material------/Z f..___--_Total length-------4--Q-------------------------- <br /> i\1 <br /> Seepe Pit: Distance to nearest well. t1_�._______Distance from fflun ation--- fll��_�.-.. to ice to nearest I lir <br /> Number of pits---1--------- -------Lining material S Diameter---------d----------Depth ------------- r�1• <br /> Cesspool: Distance from nearest well-----------------Distance fromc{ nda ion....................Lining material-------------------------------------- G <br /> ❑ Size: Diameter---------------------- --------------Depth----------------------------------- ------ ------Liquid Capacity----------------------------gals, S <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__-------_-__----_-----____-___---_--. \ <br /> ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---- <br /> --------------------------------- ----- — <br /> Remodeling and/or repairing {describe)--- <br /> -------------------------•------------------------------------------------ ------------------------------------------------------ <br /> --------------------------------••----------•------- ------------------------------------------------------------ <br /> -------------------------------------------------------------------------------------•---•------------------•-----------------------------------------_...... ---------------------------•----------------------------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)---- -- ----------------------------------------------------------------{Owner and/or Contractor) <br /> By:. Z_A�. -- ------------------------------------------(Title)------'1 <br /> ---------------- ------------ <br /> qLA <br /> plan, showing size of of, location system in relation to wells, buildings, etc., can be placed on r0erse side). <br /> FOR DEPARTMENT USE ONLY <br /> 4� RATE �. r <br /> APPLICATION ACCEPTED BY---------- --- -------- - ' <br /> -_ DATE <br /> BUILDING PERMIT ISSUED <br /> REVIEWED BY---------------- ------------------------- ----------- --------------- --------- r - ------------------------------ <br /> w DATE ------ <br /> Alterations and/or recommendations:--------- _/------------ f.. •-----------------------•--------------------------------------- <br /> „1 <br /> -----I-------------------------•--------------------•---- ty <br /> -- ------------------------------------------------------ -----•- ----------------------------------- --------- <br /> FINAL INSPECTION BY-- - - - ------- ------------------------------------------- Date--------------------------- -------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-21A 145446 ATWOOD 12-54 <br />