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7 APPLICATION FOR SANITATION PERMIT Permit No. 4 [Complete in Duplicate) 1� ] k� T Date Issued .3 �s7- Ppplica&ion is hereby mads to the SanJoaquin Local Health District for a permit to construct and install the work herein described. is application is made in compliance with County Ordinance No. 549. I JOB ADDRESS AND LOCATION ,... �f` �� ----------- Owner's Name--------- �� 1 1 ".+rr- ---------I------ -- ------ Phone------------------------------------ Address............ ------------------------------.----Address________.... 1 --------------------------------..------------------------------------------------- '---------=---...------------......------- Contractor's Name s ------------------------------------------------------ ------------------------------------------------ Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living .�_ units: ________ Number�of bedrooms __--____ Number of baths ___- Lot size ------------------------- 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 ❑ Aclobe�k Hardpan ❑ Previous Application Made: Yes ❑ No`' k New Construction: Ye>g�No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank.or cesspool permitted if public wwhis available within 200 feet.) Septic Tank: Distance from nearest welL,kk_Q_______Distance from foundation_L Q_________._.Material_____ _______. No. of compartments:...:-"I----------- Size__ 1��_,(-_4.-------Liquid depth.....�"�---------------Capacity---i-SU_.4-------- Disposal Field: Distance from nearest well-.�_.._..._Distance from foundat'kon_-.1_G?____.__._-Distance to nearest lot line__._____-__. Number of lines__' _Length of each line___.- _Q--Q-.��___.._.Width of french__._, _��______________._ Type of filter material-- D �&er material-,A.-1?-. , _.__.Total length----)-_Q...0------------------••--.- ..- Seepage Pit: Distance to nearest well______________________Distance from.foundation--------------------Distance to nearest lot line__.______.__.._ ❑ Number of pits--------- -----------Lining material.......................Size: Diameter----------- --- Depth----------------------------....- \ i t k Cesspool: Distance from nearest mall---------------- -Distance from fou" dation.___.._.............Lining material---------------------------------- ❑ Size: Diameter---------------- -----------------.Depth------------------:-- - Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------- ---Distance from nearest building-------------------------------:---------- Q ❑ Distance to nearest lot line----------------- ---------------------- Rdeling and/or repairing (describe):_`_ ' ------ `-�••- - k ------------------------------------ ---------------------------- - ------ - ----- •-�-+ ��' ' --------------------------------•-----------•------------------•-----------------•---------------- -- --------------------- ------------------------------------------------- •--------------- 1 .. 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 regaletions of the'San Joaquin Local Health District. '-"""~------------- -- (Owner and/or Contractor) (Signed)-eche', ------ - Sy=------------------------------------------------------------------------------- ----------------------------------------------------(Title)-------------------------------------------- ------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). k. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------ ----- ----- ----------------------------------------------------- DATE------ ---------------------------------------------- REVIEWED BY-------------------------------------------------- -------------- ---- ----------------------- ------------------ DATE----- ----------------------------------- BUILDING PERMIT ISSUED----------------------------------- --- - DATE--------- _ AI rations and/or recommendations:__..__-- - ---- t r -------------------------- y k v FINAL INSPECTION BY------------ -- -- ---------------- - -----------v 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 ` es—s 145446—WOOD N