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APPLICATION FOR SANITATION PERMIT Permit No. . _;� .4-1 (Complete in Duplicate) Date issued :v�a--,s-4 Application 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 rdinance No. 549, JOB ApQRE85 AND LO ATION- G--G--�----- - : -------• ----------------- ----------------------- Owner's Name---__---- It. ..... . Phone------ -- Address---------- rf .+�.- . 1 •-------•-------•--•-----•-----------------------•--- Contractor's Name-------------- Phone -- -•-- Installation will serve: Residence, Apartment use ❑ Commercial ❑ Traile curt ❑ Motel ❑ Other ❑ Number of living units: --6-_ Number of bedrooms - -- Number of baths _-: Lot size ----- ----•------ -------------------- Wafer Supply: Public system ❑ Community system ❑ Privateg Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Ye o,❑ /1 , 1 3 TYPE OF INSTALLATION AND SPECIFICATIONS: ,r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T 5k: Distance from nearest well_e O_-._Distance from foundation—----Material ------------------------------------- No. of cornpartmenfs-----------------------------Size------•--- ----=--------------Liquid depth---------------------=----Capacity---_ - f Disposal Fiel Distance from nearest well_ Q---Distance from foundation------3_9'.72---.Distance to nearest lot/fip;-- Q-' Number of lines---------I----------'.-_.--- ----.Length of each line-----/p0- 01------Wi fh of french c�7" - Type of filter material-_,5-rC---De----Depth of filter material '0"' p 4-r. ength-----`-�.��........................- --------- 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'--_---_-------_--__--------------. k ------------ ------Depth----------------- ------------------Liquid Capacity------------------- Privy: ---- ---- _.gals. -❑ ,. .size: Diameter-------------- -------------- Privy: Distance from nearest well-----------------------------------------------_-Distance from nearest building ❑ Distance to nearest lot line------------- ------------------------------ , Remode€ing and/or repairing (describe)----------•--- r ._ bQ�-- ---- -- O� �� ----------------------------------------------------•---------------------------------------------------- - �". ------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State S, and rules and regulations of the San Joaquin Local Health District,yw (Signed)--- --- - --- --------- BY: ,. ----------------------------------------------- - (Owner and/or Contractor) - - --------------------- By--------- -----•--------------------•-------------------•--------------------------------------------------------------------------Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------- ---- ------ ----- ------- -------.----- ---- ----- - DATE REVIEWED BY -------------------------------------------- DATE- -- - - LL -------------------------- SUILDING PERMIT ISSUED--------------••------------------- -- -�-----�- --------------------••---------. DATE--- ---------------------------------- •- -- Alterations and/or recommendations---------------------- -- - -- ---------------- ---------------------------------- ---------------------------------------------------•---------------------------------------------------------------------- r ----------------------------------------------------------'� '' - - g FINAL INSPECTION $Y:. ---- ----------- ------ ----- f--' Date------ - ----1-_f-..77--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy,.California E5-9-2M 10-52 Revised W-2900