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// �7 / I APPLICATION FOR SANITATION PERMIT Permit No. .___la./_.72 I {Complete in Duplicate) Date Issued ----- _S 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 rdinanw No. 5 9. JOB ADDRESS AND LOCATION01-.9-Z ' Owner's Name--• ' -- - ---- ------------------------------------------- Phone----- ------------------------------ Address ...._..... - -- - -- Contractor's Name__.-- ---- __________ ________ __ Phone '+ _' .----4 Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I--- Number of bedrooms ____Number of baths _/----- Lot size ___- _____x____ '____________________ Water Supply: Public system �ommunity system ❑ Private ❑ Depth to Water Table _a ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 6�ardpan ❑ Previous Application Made: Yes ❑ No El--New Construction: Yes ❑ No Ef-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept- Tank: Distance from nearest well_________________Distance from foundation--------------------Material------------------.------------------------------ No. __`_______________..______-No. of compartments------------ - ----- ---Size--------------------------------Liquid depth--------- ----------------Capacity----------------------- isposal Field: Distance from nearest well_________________Distance from foundation_______________.__.Distance to nearest lot line_______________- . -- ----------------------- Number of lines----------------.-------------.----Length of each - Width of french---------------------------.--___-_- Type of filter material-----------------------Cl ? material-------- ------ --.---Total length--------.-----------.------------- ------- D S r 0 Seepage Pit: Distance to nearest wellAt� - -- f•ouf dation--- Distance to nearest lot line--"-'-�-a------ W }-� Number of pits._.____l____-___-__Liningh-.Size: Dia ter._t�. _��...___Deptn__ __._____________Cesspool• Distance from nearest well-_._________.. foundation__ ________________Lining material__.___-__________-_.____.____________.Size: Diameter----------------- - ---- -- ----------------Liquid Capacity----------------------------gals. , Privy: - Distance from rearest well-_____________-------------------.--------------Distance from nearest building_.__._______.__________-_____._.__.___- ❑ Distance fo nearest lot line---------------------- ----- ------------------------------------------ ----------•-------••-------------------------••-•------------------- i o Remodelingand/or repairing (describe}------------------ ----------- ---------------------•-----------------------------••-•-•------------•----------••------••-------------•-•---•-------- g ---------------- --•-----------------•-------------•-• --------------------•---•-----------------•-------•------------------------ - ------------------------------------------------------------ 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 regulati ns of the San Joaquin Local Health District. (Signed)... - .- .--.----(Owner and/or Contractor (Title)---------------------------------------------------------------- By:.. ----- (Plot plan, A wing 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----------------------------- DATE-------------- -------------•---------------------------- tz- - -- REVIEWED BY -� DATE 6;--- BUILDING PERMIT ISSUED__..--•----- �� ---- DATE `- ---- - ------------------ I-------- Alterations and/or recommendations:------------------ ---------- . ' _________________________ ---- ' �}r� - - -►------ -- lte CX? ----------------- ----- -------- --- -•----- - ------ 7------ -------------- ------- .. ---•-------------------- ----------- ----------------------------------------------------I --- ------- --------- - ------------ ----------- ---- ----- - ------------------------------------ ------------------------------------------------------------------ FINAL INSPECTION BY;_. -- --------- Date_----�Q.-- 1--Q��t --------------- 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 E5-9-2M 345446 ATWOOD 12-54