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-9 z APPLICATION FOR SANITATION PERMIT Permit No_ _____________ (Complete in Duplicate) Date Issued 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. 549. JOB ADDRESS AND LOCATION_. .Q_4 l� . ------`•------------'------------- ----------------- ' R � �ti� _v Owner's Name ffzC �J _.G,.r)4----------------------- ----- -------------------- Address ------------------ ............... Phane Address-----------�c Jr....... --------------------------•-•--------------- •--------------------•-•-------------------------••--------------------------••- Contractors Name---------------------------------------------------- ---------------------- --- ---------------------------------• --- ------ Phone----------------------------------- Installation will serve: Residence ru'r Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � y Number of living units: ___f___ Number of bedrooms -------- Number of baths __Lf__ Lot size -- --1 __________________________ 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 ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ I Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ l 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_________________Distance from foundation-------------------.Material--------}.__._____.______...__.___.._..___.____. x, ❑ No. of compartments--------------- ---- - ---Size--------------------------------Liquid depth----------- ------------- CapacitY----------------------- j Disposal Field: Distance from nearest well______________ __Distance from foundation--------------------Distance to nearest lot line---__......... ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------------------.--------- Type of filter material_______________________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-----_--------------._____--_--____.-. WO ❑ Size: Diameter--- ----------.. Depth--------------------------------- ----------__-Liquid Capacity---------------------------gals. O ------- Privy: Distance from nearest well.... iT']-�. ,_____.-------------Distance from nearest building....... �� ____-----------_________ K'l . .._.,._, Distance to nearest lot line-------�--{-------------------------------•-------------------------------------------------------------------------------------------- Remodelin and/or repairing (describe):--7 -------••-k- -------------•- -----------------------•----------------•---•-- ----------------- ------- --------------- ----------------------------------------------•---------------------------•---•--•------ -----------------------------------------------------••-------------------------------------------------------------------------- ----------------------------------------------------•--------------.--------------------------------------- •----------------------------------- ----------------•------------------------ -- ---- -- 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. f .__ ---- and/or Contractor) (Signed) By:-------------------------------------------------------...------------------------------------------ •------------ (Title) "3 (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-- --- ---- ......... ------------------------------------------------ DATE-- �.��--------------------------------------------- REVIEWEDBY------ ------------------------- - ------------ --------- --------------------------------- DATE-------- --• ----------------------------------- BUILDINGPERMIT ISSUED------------------------------- --..._<-- .---------------- - -•----------------------------- DATE.--------_-••- - ----------------------------- IAlterations and/or recommendations------------ ------------------------------------ --------------- ----------------------- ------------------------- !•••?------------------------- --------------------------------------------------------- ----------------------------------- -------- --------------------------------------------- ------------------------------------------------------------------------------•------- .-------------------- -------------------------------------------------------------- --------- ------------------------------------------------------------ ----------------- -------------------------------------------------------------------- ---------------------------------------- - - -------------------------•------- ----- ----------------------------------- ---------------------- ----------------------------------------------------------------------------- FINAL INSPECTION BY:------- - --- -- -�-------------------------- Date---- �-- -�=...... _.._.�-5---- ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT a r 130 South American Street 300 West Oak Street,- 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California r ES-9 145446 ATWOOD