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APPLICATION -FOR SANITATION PERMIT Permit No. (Complete in Duplicate) • �/ S Date Issued ______ --------- A ________ Applica}ion is hereby made to the San Joaquin Local Health District for a permit to construc and install the work herein described. This application is made in compliance with County Quina No.t 49. " � - � 2 a JOB ADDRESS AND LOCATION_ - r------ - -- 5 � � F Owner's Name------------------------------� _*x_7l..---• . - �'►'1- '�'?'t• q�'�f r ---- hone Address----------•------------------------•------------------- dar-------- ---- -� ''"r`- -d *- -$- _-------•------------------- Contractor's Name................... Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ .r Number of living units: __f__ Number of bedrooms _ r_ Number of baths __/--- Lot size _- y--------------------------------------------------- Water ____/-3ae___________________ ____ Water Supply: Public system ❑ Community system ❑ Private,( ] Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Vj, Clay Loam E] Clay ElAdobe E] Hardpan ❑ Previous Application Made: Yes E] No 70" New Construction: Yes [ o ❑ 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_' -0 rrti.r.Distance,fromoundation__Z0 ' �<Mat dal_-- _-�--i' '_'__-._per +------ ® No. of compartments-------- ---------- ----Size--- Liquid depth------ ----------------Capacity--- ------ Disposal Field: Distance from nearest well_SA _1__101stance from foundation--- Distance to nearest lot line___-�------ �'+�-+�°-- © Number of lines---------- _____ ______ __ Length of each line--------- _ _ Width of trench___ ______..____________ ------------ rial-___ r n_______._Total length-_______ - _�.? ____________ __ Type of filter material------t -Depth of filter mate Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------_-----.Distance to nearest lot line-------.-__._____ 0 Number of pits- - ------------------Lining material------------ Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well----_------------Distance from foundation____----------------Lining material-------------------------------------- ElSize: Diameter--------------------------------------Depth-------------------- ----------------------_-- ---Liquid Capacif-y=---- -=-gals. Privy: Distance from nearest well------ _______________________________Distance from nearest building------------------------------------------ _E1 Distance to nearest lot line_________________________________ Remodeling and/or repairing (describe)--------- - -----------------------------------------•---...-------------------------------------•----------------------------- --------------------------------------•------------------------------------•---------------------------------------------------.-..-..--•----•--•--------•----- -------------------------------------------------------------- - ------- -------------•-----•----------------------------•----------------------- --•----------------•--------------------------------•---•--••---------------•------------------------------------------------------------ ----------------------- --------------- --------------------•-------------•------------------••-•-----------------•-------------------------------•------------------------------•-------------------------------- 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. ( 9ne Si d)--------------- ----------- ---------------------------------- - (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-- =" f --- ------ -- ------------ DATE------- - ,3/ -- 5- REVIEWED BY----- --------------- DATE -- BUILDINGPERMIT ISSUED------------•------------------------------------- --------------------------------------------------- DATE------------------------------- ---------------------------- Alterations and/or recommendations------- -----------------------_- ----------------------------•----------------------------••-----•-•-------•-----------••--•----•------------- -----•----------------------------------------•----•------------------------ ------------ ---------------------------------------------------- -- •--------------------------•----•------------- ------------- ..__... FINAL INSPECTION BY:.- Date......... �/' �� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California 1•r ES-9-2M 145446 ATWOOD 12-54