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,1Ij APPLICATION FOR SANITATION PERMIT ERMIT Permit No. 4 (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permi 0 R'--r )et a d install t or herein described. This application is made in compfian with Aunty Ordinance No 549, � -7 � �:., �FZfr wl. �✓,4r..�,t r- JOB ADDRESS AN LO`dlO Owner's Name_ + ----------- � r �j ------------------ ----------- Phone _"`_ Address------------- f'F' 70--------- &_0 -- ---- ------- Contractor's Name...___.. ------------------------- -----•--------------------------------------------------- --- ----------------------------- •--------------- -------------- Phone----•----------------------•-- Installation will serve: Residence Apartment House ❑ Commercial ElTrailerCourt E] Motel ❑ Other Number of living units: -___ Number of bedrooms -------- Number o baths _7--- Lot size S� - } . ca Water Supply: Public system - -�- PP Y� y ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel L❑ Sandy Loam ' Clay Loam ❑ Clay E] Adobe Hardpan ❑ - Previous Application Made: Yes ❑ No ER/ Construction: Yes ► No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer)is available within 200 feet.) t Septic Tank: Distance from nearest welo_- 1 - ----. istai, e fro oun,da�ion----/ Z--------Mate i j---- ---- ►►LL�I No. of compartments___-_ ____. __ f. 'Siz _ _. Liquid deh --- ------ --------Capacity---- Q Dispos Field: Distance from nearest w l -___5/ � )stance from foundation__ �d�____._.Distance to nearest)4' in ._ ----�- - F, Number of lines__________ ___ Len Length of each line_________ _ -------- Type g Q- *f...Width of trench--_-_- - T e of filter mater) _ -- - -------------- Seepage of filter material-_ � Total length_ *------------------ Seepage Pit: Distance f nearest well_.__________".________Distance from foundation___ Distance to nearest lot line---------------- -----Lining , ❑ Number of pits--------------- material-----------------------Size: Diameter -------- ---Depth------ ------------------------ Cesspool: Distance fi-om nearest well-----------------Distance from foundation._.-----------------Lining material_ -" J Size: Diameter--------------------------------------Depth------ -------- ----•------ ----- Liquid Capacity_ ---------: -------gal`- Privy: Distance from nearest well_---------"------------------------------------Distance from nearest building ❑ Distance to nearest lot line __________________ _ ---------------•------------------------------------- ----- - Re 6deling�and/ "r rep�irin de cri .-"--""""--.-- --"""--".- -.----" - _ 3 g W):- -----------------------: - ---------------- ----------------- -•--------------------- -------------------------------------•--- ------------------------------------ ------------ ------------------------------ cation and that the work will be done in I hereby certify that I have prep d Vs appliaccordance with San Joaquin County ordinances, State laws, and rules an regulbti s f the San Joaquin Local Health District. (Signed)------------------{ ---------------------- ------------------------------------(Owner and/or Contractor) By-------------- ---------------------------------------• Tale ____ (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_C DATE_---------------------------------------I--------- ----------------------------------------- REVIEWED BY------------------ --------- ---- ---- - -- ----- ------ ---------------------------------------------------- ------------------------ ------------ ----. DATE_ ----------------------- UILDING PERMIT ISSUED --------------------------------------------------------------------------------- DATE------Qf\ Alterations apd/or recommendat s:-------- ---•-----------_ � __ r S `�--------- - , - -------------------------------- ------------------ ------------ ------------------------------------------------------------------ -:-t---------------------------------------- -- ------ - -----------------------'I ,, -- ------------------------- FINAL INSPECTION BY__ __"" -f� L�_ -------------- ) -- l' S Date U SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C" Street Lodi, California Manteca, California Tracy, California E$-9-2M 10-52 Revised W-2100