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APPLICATION FOR SANITATION PERMIT Permit No.S.4.3___ _. (Complete in Duplicate) .. Date Issued -67-9 Application is hereby made to the San Joaquin Local Health District for a permit to cons ct and install the work herein described. This application is made in compliance with County Ordina No. 549. -- - - -------- --- JOB ADDRESS ANDv� C, . - Phone------------------------------------ Owner's Name------- - -----• - --- ------- Address -- Address--------------------- ,-- -- - ----- --------'- --- ----- 1 .------------------------------------------------ Contractor's Name--------------- --- ---------------- ---------------------------------------------- ---- ------------------------ ------------ Phone----------------------------------- Installafion will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___r___ Number of bedrooms _Number of baths __.I___ Lot size Wf - T . --- ' Water Supply: Publics stern -Communit system .❑ Private Depth to Water Table Y ❑ Y Y �1 Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobev Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes F] No TYPE OF INSTALLATION AND SPECIFICATIONS: . \ (No septic tank or cesspool permitted if public sewer is available within 240 feet.) Septic Tank: Distance from nearest well___ 0_t_Distance from foundation---- .0----.____ Mat -- ------Liquiepth--------- ICapacity -_-_-_-No. of compartments--------------------Size..Iv- er Dispo --t ---.-_-. j aI Field: Distance from nearest well--4 Q-f-.._.Distance from foundation____��3._____._.___Distance to nearest lot line___�_�lr Number of lines-------J--------------------- --Length of each line-------1Q-0-- ------- Width of french------30-el-_------------------ Type of filter material- Depth of filter material-__:TO-"----- length___14_+0_________________________ Seepage Pit: Distance to nearest well---------------------- 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__--__------__.____-________.______ = ❑ Size: Diameter--------------------------------------Depth---------------------------------- -----------------Liquid�CapacitY :__----. --------- a{s. - Privy: Distance from nearest well________________ ________________________________Distance from nearest building.__________-_____--________.__..__..._. ❑ Distance to nearest lot line----- --------------------------------------------------------------------------------•----------------------------------•-------------- Remodeling and/or repairing escribe :_ s ._� "4.� ------•------------------------------------------`"-`�,_. ----------- / -- --- .... !_ _ I .- - - �e------------------------------------------------------------------------------------------------ - d �--� I hereby certify that I have prepar this application and that the work will be done in accordance with San Joaquin County ordinances, State law, and ru an a la ' ns of the San Joaquin ca Health District. (Signed) s-- --------------------------------------------------------(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-------------------------- ------- - DATE------------ ---L______ -- --------- REVIEW)=D BY ------------------ DATE ------------------------------------------ -- ----- --- ---- - ---------------------------------- BUILDING PERMIT ISSUED---•------------------------ - --------------------------- DATE = Alterationsand/or recommendations------------- ---- --------------------------------------------------------•----------------------------------.-------••---•--•-------------------------------- -------------••----------------- ---------•-----•--------------•-----• ------------------------------------------•--------------------------------------------------•---•-------••----------------------------------------_ -----•-• ---------------•---------------------------•---•---•--------------------- --- --------------•-----------------•---------------------------------------------------------------------------------------------------- -----•----------------------------------------------------- -•--� - -----------•----------------- ------------------------------------ ----------------------------------------------- -------------------------- ------•------------------------------------•---------------------------------------•--------------------------- ------- "/0 --._.._. FINAL INSPECTION BY:_____________ __________ �`Q i - - --------------------------- Date ' 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 tS-9-2M �0-52 Revised W-2l00