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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 and install th6 4work rein described, This application is made in compliance wiih Countynanc N( 549. JOB ADDRESS AND 'LOC TION__ __ --- _ aor - ----- _4�1041------------------I--------------------- ----------- Owner's Name--------------j -------------- --------------------- =-- ------- Phone---- -Q-,.�`1__f_.5r- Address------------------------- -_ -------- ---- Contractor's Name — - , / '7� � ` + = Phone._,h Installation will serve: Residence Kk-� partment House E] Commercial ❑ Trailer Court ❑ Mot Other ❑ Number of living units: __�__ Number of bedrooms ___X"'Number of baths __ ___ Lot size _____�X-- ted ---------------------------- Ae Water Supply: Public system ❑ Community system ❑ Private p'th to Wafer Table ft. Character of soil to a depth of 3 feet: Sand .Gravel Sand Loam Clay Loam P ❑ ❑ Y ❑ y ❑ � Clay❑ AdobeHardpan E]Previous Application Made: Yes Eli No E4-_—'New Consfruction: Yes 0 No Ek-�<HA/VA: Yes E] No E�' , � TYPE OF INSTALLATION AND SPEC IFICATIONS:NSI ebIL- _ (No septic tank or`cesspoolupermitted efepew ublic sila .within 200 feet.) _,. Septic Tank_ distance from nearest rwell__t ._f�___-__Distance from'four afion__._ /_____.Material_ '-_______________________------___--•__--- No. of compartments------7�_______Size-,r - � - _t'Liquid deph---�7„.`-.Capacity____ r osal F” Distance from nearest well-_Dista`nce Trotfoundation___1 '__.Dis#once to`�nearest lot line.�_� Numb, of lines________1__ - ___ Lengfih of ea h line_____ Q_�-- ______ Width-of trench-_--=X$e -------------- e091�A ,r r �-i ., d Type a filter matrial.____ _ rK ! ___:Depth?of falter,material___-__---��----Total length,____-___L�,�_�------------------- See�: Distance to near;sstwell= 9 - Distance m ounclation _Q _ _____.Distance to nearest lot line- __ __ Numberuzof pits_`- _ _LiningPrnaterial- _' _ Size; Diameter.-_413-0/__--_.De th_.._ 1 i >� ',. � . � P .--w5-------------- Cesspool; Distance from nearest well___.-r++----_Distance-from foundation------------------- Lining material-___________________________________. �I ❑ Size: Diameter--------------------------L---Depth`_ ----#---------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well_____--__.�.____ _-- ___-----_!-----------Distance from nearest building ❑ Distance to nearest lot line-,�=_-----I____-`__:-------, y ..__---- ------------------------ +r Remodeli and/or repairingdescribe :__._ _-------- 1� ---------------- ------------ - fN-------------------k� "s f ----------- ----- _ I ---------------�----fig- •---------- --------------- f ---- t I herebycertifythat I have re pared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of ithe San Joa utn Local Health District, f --------- - . 1. - ---------------- --- - �-Contractor) BY:------------ -------------------------------- =--------------------------'I------------------------------------- --- -- ---------------------- By: tle _._ --{Title)- ------------------------------ - - (Plot plan, showing size of lot, location of system in.relation wells, buildings, .dtc., can be placed on reverse side). .(. FOR DEPARTMENT USE ONLY ', APPLICATION ACCEPTED BY ---------- ---------- ---------•--- DATE 4 '°if ----- ------ fr REVIEWED BY-------------------------------------------------------- - ---- ------------------------------------------------ DATE BUILDING PERMIT ISSUED------------------------------- A __ ----- ------ DATE----- - ------------------------------------------------------------------ -------------and/or-recommendaf ions:-______.:____""". __ ------- ---------------------- -------------------------------------------------------- ----- r --------------------------------------•------------•--------------- -•------------------------------------------------------------------------------------------------------------------------------ =------------------ -------------------------------------------------------- ------------------ ------------------------------------------------ -I---------- ------------------------------------------------------------ -----------:--------------- Da FINAL •-------- ----- ----------------------- FINAL INSPECTION.-BY-------- ----s- -------- - Da te__f ------------------------ _� _ - ? 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 . Revisea 1.57 F-RCO.