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APPLICATION FOR SANITATION PERMIT Permit No. ___ . - 4 - (Complete in Duplicate) Date Issued ----------------------- Applica-lion 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. egJ013 ADDRESS AND CATION---•---•- --_,- _� --------------- .___L / _.-I----------L-/V , � ---------------------------•----------------------------------------- Owner's Name-------- i'�-------=� Gs.•i � ---------------------- - ------ -------------------------------- ----------- Phone----------------•------------------- Address.......... 17-4� ,y� ------------------------- ---------------- -------------------- ------- -- _ r}-------- Contractor's Name-- Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:.' _/._._ Number of bedrooms.,-'_- Number of baths __j--- Lot size . _��` _ �_ ____________________•.`�� Water Supply: Public system J2_Community system ❑' Private ❑ Depth to Water Table ZO. ft. V Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: ,Yes ❑ N.o [ems New Construction: Yes g- No ❑ { _ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance #rom nearest well_________________Distance from foundation--------------------Material----------------------------------- -------------- - o. of compartments-------------------------Size.-----------------------•-------Liquid de th---------------- -- -- Gapac,tY---------- ••------=- `I -_ Disposal Field:% from nearest welt_________________Distance from foundation--------------------Distance to nearest lot line----------------- umber of lines------------------------ ----------Length of each line------------------------------Width of trench---------------------------------- istance w Type of filter material--------------------------Depth of filter material--_..._.___._._-___._Total length__________-_______________________-____.- Seepage Pit: Distance to nearest well-- (3 pistan u - n------ Distance to nearest lot ne__r Number of pits.----(---------------Lining mate al: �_' Diameter-------'��-------Depth-,",,------ ----------- p ' �.__ay F Cesspool: Distance `from nearest well-----------------Distance from foundation_ --____________.Lining material------------------------------_------- F71meter--------------------------------------De Depth ------------------------------------------------ Li id Ca acit pu 9. P Y gals. Priv Distance 'from nearest well---------------- _? Distance from nearest building ------------ --. ❑ Distance to nearest lot'line--- ----------------------------------- -- Remodeling and/or repairing(describe)--------------------------------------------- ------------------------------••--•----------....-----•--------------------------------------------------------------------------------------------- i �I •--------------------------••----------------•--------------------•-•-----------------.._...----------•----------------------- ---------------------- •---•--2----------------------------------------------------------.-.-------------------------------------•---------------------------- i ------ ----------------------- -----------------------•---------...---•-_._----._..»..-------...--•-----------•-------------.-....-.....--------•---.-.-_._--__-___--.--------------__.----••---•------••----------------•------- I hereby cert'�.�r�--F{,at I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, StaI�a s, and rifles and regulations of the San Joaquin Local Health District. I� (Signed)------------- -- --------- -----`---------- •---- --------- --- -------------------------------------•-----------------(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). j� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BAY-------------------------- ----- ------- ------------ ---------------------------------------- DATE----- BUILQiNG PERMIT ISSUED DATE----- `..� -••----------------------------•-•---•-- REVIEWED BY----------------- -- 1------------- DATE----- --- -- - Alterations and/or recommend ations: �._ --•-------------- --- ---- ;, r IM. FINAL INSPECTION BY:. Date = - •-------------------------- I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California EE---9-2M 145446 ATwono i2-54