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APPLICATION FOR SANITATION PERMIT Permit No. _4 (Complete in Duplicate) .•� Date issued Applica-1,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 OCAT�ON-�'��.�---------- ------------------ ------------------------------------------------------------ I ----------------- --- -------------------------•--------- Owner's Name------. r�� ----------------------------------------------- ------------ Phone_ - AddressG !0!..�C.----------------------------•--------------------------------------------------------------•--'------------------------...---•----------------------------•--- - Contractor's Name ��_'� --------------------------- Phone_..- = Installation will serve: Residence &Apartment House ❑ Commercial ❑ Trailer Court ❑f Motel ❑ Other ❑ Number of living units: I____ Number of bedrooms -1__ Number of baths � I r ------- Lot size - --OO_K-, !. �-------------------- Water Supply: Public system T--Icommunity system ❑ Private ❑ Depth to Water Table . ___ ft. k Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑; Clay ❑ Adobelardpan ❑ Previous Application Made: Yes ❑ No 2�New Construction: Yes�`No ❑ 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__�tr*.�e.R+Distance from founda+ion___/&1 ----.--Material_____�Y* '` j_..__________. No. of compartments --------------___Size___ Li Liquid de th____-Z____--_--Ca Capacity :__._______- { s� p - - WJE--�k-X--:�------ q p - ►f ---- p Y--- ---- � �1 Disposal Field: Distance from ne t well-_>2'" Distance from foundation;f1O-.41--_-__.Distance to nearest lot line__V__.________ Number of lines__ _______________ _ Length of each line_`_lAS' S--10-Width of trench-f_vi_�_-_.___.____.____ kL Type of filter materiaL _____Depth of filter material----1r._l..._______Total length________ 1____ --------------------- Seepage Pit: Distance to nearest well --------------Distance from foundation--------------------Distance to nearest lot line_.__________. -_ iJ11 ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------•---------------Depth--------------------------------. Cesspool: Distance from nearest well-----------------Distance from foundation---------- ---------Lining material---------------------__-__________. (� ❑ Size: Diameter------------------ ------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. �• 7 Privy: Distance from nearest well------_---_------------------_-------------------Distance from nearest building-_'. 1 ❑ Distance to nearest lot line----------------------------------------------------------------•------------- -------------- -----•----------------•----- --------- Remodelingand/or repairing (describe)-------------------------------------- -----------------------------------------------------------------------------------•--------------------------- ---------------------•--------------------- ----------------•-------------------------------------------------------•--------------------------------------------------------------------•--•------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, t to laws, and rules and regulations of the San Joaquin Local Health District. (Signed) ---------------------------r----------------------------------------------------------- -----(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_____ REVIEWED BY------------------------------------- --- DATE_ ._'� -GS -- ----------- --------------------------------------------- BUILDING PERMIT ISSUED----------------- ------ DATE--------- --------------------------- Alterationsand/or recommendations------- -----------------------------•---------------------•------------•----------------------------------•--------•-------•-• •------------------------------- -- --•---- //------,---� -1-----�--------- --------------------- ---- ------------ ---------------------- L - --------- = i ------------------------- ----------------------------- - ------------------•--------------------- ------15------------ ----- -------------------------- -------- ------------------- FINAL INSPECTION BY:__ ---------------- Date �`- J 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 ' FS-9-9M ; Revised W-2100