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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct arad install the work herein described. This application is made in compliance ith County Ordinance No. 549. JOS ADDRESS AND LOCAT N ---14 --- '3 C`za C` '�- """" Ri Owner's Name-.---�----` �3/1.r - 1�L-------- --- Phone------------------------------------ Add ---------------------------------------------------•--------- Contractor s Name--Q. - •-e--- eartment Phone. --- -- ----- --- - ----- -------- ------ --------- Installation will serve: Residence KI House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 Number of living units: Number of bedrooms --3-- Number of baths ---/-_ Lot size ----75_-�.(---j--?-j-----------------__--_----_ Water Supply: Public system ❑ Community system LK Private ❑ Depth to.Water Table -------- ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ .Adobe XJ Hardpan ❑ Previous Application Made: Yes ❑ No iq New Construction: Yes 1 No ❑ FHA/VA:`Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) ``. a Septic Tank: Distance from nearest we11!�•xP-----Distance from foundation-----/!P.........Material-----�i4a� Iyl --------- _ ---------Size---- ---'�-�--A----------Li Liquid depth---'i�-------------- Capacity.- 'P � i No. of compartments_________________ f q --- Disposal Field: Distance from nearest well-. Distance from foundation---10--- -__-_-Distance to nearest lot line--LS -----_ [� Number of lines- --_-___ g -7- ` ` " 1 2_________----__._---Length of each line----- -tS------------------Width of trench-- -f✓-----_----..--.-.------- } l Type of filter'material-_--_7?o-G "\e _--____Depth of filter material ------18'___`""-.--_Total length-----1st'------------------------ Sum11p : Distance to nearest.well-----Ike_ha ---_Distance from foundation___.,r''b_._.------Distance to nearest lot line-- - �'- --_-_- ® Number of pits-------:,---------Lining material------- .4_C-f(--.Size: Diameter..-,' x__ ---------Deptn__f---------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------.-__..Lining material------------------------- ❑ Size: Diameterth------------ DepLiquid Capacity gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------__----_------------. ❑ Distance to nearest lot line------ -------------------------- ------------------------------------ ------------------------------------------- Remodelin and/or re airin describe ------- ------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------=----------------------- ----- ----------- --- --- --- --- - ---------------------- ----------------------------------------------------------------------------------- ------------ -- ------------- -------- ----------------------------------------------------- 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. (Signed) 0 --.- --- -------- ----------- -------------------- By: -----------------------------------------(Owner and/or Contractor] - - ---------- By:------------------------------------------ ---� ---------- - ------- -------------------------(Title)----- 4 ------------------------------ (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- MP...-------------------------------------- ---------------------------------------- DATE----- t _-30_-5_ ----------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED---------------------------------- ------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:------------ --------------------- ----------------------------------------------------------•--------------•---•-----•--------------•--- - -- - ------------- -------------------------------•---------------------------------------------------------------------------------------------------------------------------------•-------------------------------------•-------------------- •----- - ----------- --------- ---- ---------------------------------------------- ------ ---------- ----------------------------•---------..-. -----------------------------------•------------------ •- ---- ---------------------- -- ---- --- --- --------------------------------------------------- -- ------ --------------------- --- ----1- - _ ------------- ------•----------------------•------ ----------------•-------------------------------- //II FINAL`'INSPECTIO a � ------- ------ Date-------- `�-1 ' a��---------- ----------------------------- 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 ES-9-2M Reviseo 1.57 F-RCO.