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APPLICATION FOR SANITATION PERMIT Permit No. 4 [Complete in Duplicate) 10 0�� Date Issued ------ _ �� 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 Ordinance No. 54.9. JOB ADDRESS AND LOC_,6P ,N---------- �� ----.�,----�U _--------------------------------------------------------------------------------------------------- Owner's Named Address-... ------- -------------/1v--f---�$-�------------------------ ------ Phone--Jd__2d 1 : - --------------------------------------------------------------------------------------------------- Contractor's Name-------- _------ _---.------- — -------------------------------- Phone ----4 4---J - _?---� Installation will serve: Residence Eg,-71�p"artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: - ----- Number of bedrooms _t--._ Number of baths J_____ Lot size ________________________________________________.._____ Water Supply: Public system;kCommunity system ❑ Private ❑ Depth to Water Table'cxS _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [❑ Adobe [D_ --Mar -,dpan F Previous Application Made: Yes ❑ No Eg-""New Construction: Yes ❑ No /VA: Yes ❑ No [4.. 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----------------- Distance from foundation -------------------- Material ________________________________________.____- No. of compartments -------------------------- Size -------------------------------- Liquid depth-------------- - ------- .-Capacity-••-------------------- Disposal f=ield`" Distance from nearest well ----------------- Distance from foundation ----- )_o_!___ -.Distance to nearest lot line_S_f-_____ r Number of lines-------------I------------------,Length of each line -------3c?_��_s, ------.Width of french___.Z__Y____-----__.-------__---- -Q`" Type of filter material ---r_ ______Depth of filt2r material ---- -n ------ Total length -------- 3_d_) ----- __---------------- Seepage Distance to nearest well______________________Distance from foundation__L6�_..____-.Distance to nearest lot line _S-_-_ -. v Number of pits_. _.__l_______________Llning material--Y.o- 4'---- Size: Diameter__.___ _ _.________.Depth_�.S_- �__________.____ Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material____..___________________.____--_____ Size: Diameter - Depth ---------------------------------------------------- Ligui.d Capacity ---------------------------- gals. ----- - ------ Privy: Distance from nearest well ---------- -------------------------------------- Distance from nearest buil&ng ------------------------------------------ El- Distance to nearest lot line ----------------------------- - ------------------ ----------s ---- ---------------- Remodeling and/or repairing (describe):---------------- l!_ ---------------------------------------------------------------------------------•----------------------------- --------------------------------------------------------------------------------------------------------------- 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 -regulations of the -San Joaquin �Local-Health District. _-j�[Owner and/or Contractor v '1 ----- ®�"------------------�---- --------------- By:_ ------------ -�----- .. -------------------(Title)-------- ) (Plot plan, showing size of lot, location of system in .relation to wells, buildings, efc., can be placed on reverse side). FOI& DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------ ----_��------------------------------------- DATE ----------------------ldll- REVIEWED BY ----------------------------------------- ----------------------------------------------------------------------------------- DATE ------------ --------------------- ------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE --------------------------------------- --------------------- Alterations and/or recommendations: -----------------------_----------- .----- •--------------------------------------- tz- -------------------------------•-------------- - ----- 57 -------------------------------------------- _____________________________________________________________________________________ _----------- _------------------------------------------------------------------------------- __-------------------------------------- --------------------------- i' FINAL INSPEC� -- ---- Date---- .`� ��' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C' Street Sfockfon, California Lodi, California Manteca, California Tracy, California ES -9-2M Revises 1.57 F.P.CO. ..-_j