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_7– Permit Permit N -- a -- - { APPLICATIO FOR SANITATION PERMIT (Complete in Duplicate) Date Issued loZ ` S � 4 /10_� , - Application is hereby made to the San Joaquin Local Health District for a permit to constr4ct and install the wor he in described. This application is made in compliance with County Ordinance No. 49 �_ � � JOB ADDRESS AND LO T[ON--------- -- ----------------------•- - - -- ------------------------------------------------ ----- Phone--------------------•--------------- wner s ame__"_-_--------""_--- Address-------------------- - .-- --- ----- --- - -- ----- --- - - = r ! d` ------------- Phone d on - - Contractor s Name"_-- "-• Motel Other Installation will serve: `Residence Apartment House ❑ Commercial ❑ Trailer Court E] ❑ ❑� Number of living units: _ tuber of bsdrooms _ { -- Number of baths - --- Lot size ------x �"�------------------- Water Supply: Public system Community system,❑.,P.rivate []_Depth to Water Table "�_ ft. a Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ lay Loam ❑ Clay ❑ Adobe Hardpan ❑ ` ` Previous Application Made: Yes ❑ No New Construction: Yes No ❑ t TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if public se is available within 200 feet.) ] P a t i �_d _- istance from foundation-- -_ Materi I-- --------- - ----------------------- Septic Tan Distance from nearest well,f� _� ��------- �/ y y r _ Ca aci p-- No. of compartments Si e /1f1 Liquid depth p tY E1 s ff,, i�-""" ..Distance to nearest lot�ine___"_-..------._ Disposal Fie[ Distance from nearest well-1i&-Ld -- istance from foundation""" -- Width of trench_ �; Number of lines__----- ___ "" --- Length of each line-------- -- J _ Type of filter material! _a _ epth of filter material"""_ _""�____-_".Total length---__ "__�"__""___"""""_._"_� """ i Distance?fm ound tion___ _•-__---Dista�e to nearest lot line_"1Seepage Pit Distance to nearest weli_/ Q_ _-__-_ 1______Linin material. ize: Diameter_"" -------------Depth_--__ Q-- -------- Number of pits."_ - g - Cesspool: Distance from nearest -- -------Distance from foundation-"""__-"""-_"."___.Lining material"=""_- gals. Size. Diameter---- ----- --- -------- -----------Depth----- ----- -------------------------- Liquid Capacity---------- _ _ 1771 _ r :.err �y = -.r-= ��`�, r =� -�.—rte- g`�' PFiv`y"` Distance-from nearest well " __ "- D,+stance from nearest buildin ------------------- --_ ❑ Distance to nearest lot line------------------------- -"___ ------------------------------ ------------ i ------------- Remodeling and/or repairing (describe): ----------------- ------•----------- --•----------------- ----------------------------------- i ----- ------------------ -- ----------- -• ------ ---•-- --• - ------ ----- ------- - - ---- hereby cerci that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, a rules and regu tions.of the San J aquin Local HeLhDisrfrict. ""__ (O nd/o ontractor) 5i ned G � --- ---- _------ ---------------- ( 9 ] (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----------- r ------------------- REVIEWED BY-------------------------------------------- -------- - --------------- ------------- ----DATE------------------------DATE - BUILDING PERMIT ISSUED---------------------Z---------- -- -------------------------- -------- - i Alterations and/or recommendations--------------------------- ------------------------------------- ------------------------- ----------- ----------------------------------------------------- i ----------------------- ---------------------------------------------------------•---- ;------------------------------------------------- k FINAL INSPECTION BY--------------------- __ -----------------R Date l ------------------ k SAN JOAQUIN LOCAL HEALTH DISTRICT 132 S camore Street 814 North "C" Street 130 south American Street 300 West Oak Scree? Y Trac California Stockton, California Lodi, California Manteca, California Y. FS-9-2M 8-51 Revised W-2100