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.� APPLICATION FOR .5ANlTATlON PERMIT 'Permit Na..___6 L�3...._ C' (Complete in Duplicate) 3/� •. { i Date Issued Applica+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. S, JOB ADDRESS AND L C T[ON_ ® " " _ ------- Owner's Name = - -- ---------- Phone Address__ ___ I Contractor's Name___________ ____ # ---------------- -------------------- ------------ Phone-,?-_- ------ Installation will will serve: Residence ❑ Apar ent House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: _ Number of bedrooms F. Number of baths T- Lot size Y - --- - --- ---- --- -- --------------------------------- --- Water Supply: Public system/1' ystem Community system E] E]Privafe Depth to Water Table ft,f Character of soil +o-a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob� Hardpan ❑ Previous Application Made: Yes ❑ • NX New Construction: YesX No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool v �permi+ted if public sewer is available within 200 f +.) .,. Septic ank- Distance from nearest well_'------ -------Distance from foundation--------------------Material---------------- Na. of compartments--------------- ---------------------------------- Size-------------------------------Liquid depth----------- --------------Capacity A Disposal field: Distance from nearest wel ` Distance from foundation_ _-._ Distance to nearest lot Number of lines------1-----------_"""-- - Length of each line-----------1��------------ of french-------.-.e-------_.--- ---------- w -Typeof filter material Depth of filter material"°/P7a---------Total' length------ d_�__-""____" -.------ Ses e Pit: Distance to nearest weft_.-------------------- _ Distance from foundation--------------_ _ T ____-.Distance to nearest lot line-___ _ ___..._ � Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------------------------- 1 4 Cesspo Distance from nearest well-----------------Distance from founclation--------------------Lining material------------------------------------- Size: __._.____-_ ______________ Q Y- Dept Liquid Capacity----------------------------gals. r• Priv Distance Diameter nearest vrelf...------_-_--_6D_ p f - W i _____________________i--..Distance4rom nearest buildin El Distance'to nearest lot line---------_ r I , .,.. 9' y ---- ------- -------------------------------- ---------------------------- Remodeling and/or repairing describe] Ze _ -- -----------------------------------•--------- 1 } f II?-------- ------ -----------------------------•-•-- --------------------------- -------------------------------------- -------------- s I hereby certi y that I have prepared this application and that the work will be done in accordance with San Joaquin County 4 ordinances, State laws, and ules and egulations of the San Joaquin Local Health District.' � r (Signed) - �------- ar -- { ( Contractor) P ------------------------= ner�dfbr ractor) s.,. - � -----------(Title_ _� w n (Piot plan, showing size of lot, location of system in relation to wells, buildings,.etc., can be p ed on reverse a}. r r FOR DEPARTMENT USE ONLY ; APPLICATION ACCEPTED BY: DATE "-- -------------------------------------------------- REVIEWED BY F=- = -------------- DATE__ BUILDING PERMIT ISSUED-=--------- ------------------------- -------------------------------------------------------- DATE---- --9 ---------------------- Alterations and/or recommendations-L-------------------' '' - ..._ - --------------------"----"------------- --------------------- --....---------•---•--•-------- ______________________________________________________ _______________________ - -� k --_-"_."._."._"_------___--------------- ---------------- - -. a ------------------------------- FINAL INSPECTION BY:---._ -� --------------------------------- DateR.- -#--- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street . 132 Sycamore Street 814 North "C" Street } Stockton. California Lodi, California qi,'; Manteca, California Tracy, California ES-9-2M Revised W-2100