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:� APPLICATION FOR SANITATION PERMIT Permit NS�_R_-�--------- (Complete in Duplicate) Date Issued Applica{ion is hereby made to the San Joaquin Local Health District for a permit to-construct and install the work herei described. This ap plication is made-in c pliance with County Ordinance No. 549. 0 �~ I4o-o 7. B-. Fo N1 �o JOB �DDRESS AN LOCATION..._ - ------ -- ...�� -- ---- ---- ------ �, -- - -----`- --------------------- -------------------------------- -----------------=. Phone-------------------------------- ------------------------ ------------------------------ ,Owners Name.---- -- - -- - ---- -- ------ - -- . ------ - - Address-------:--._ _....__ =----------- -----------------------------•------T----�---�_' ---------------.'..6Glf------------------------ ontractor's Name:-_ -�_- r•-------- , P o e{f r Ch n _ ��/ r( �"" Installation will serve: Residence partment House E] Commercial'` ❑ Trailer Court ❑ Motel E] Other C] °V Number of baths. Lot size I --------------------------------- Number of living units: -__- Number of bedrooms -a-- � Water Supply: Public system ❑ Community system ❑ Private [ ►Bep#h'.to Water Table _ �_ ft. Character of soil to a depth of 3 feet: - Sand F1 Gravel ❑ Sandy Loam ❑)Clay Loam ❑ Clay ❑ Adobe ardpan Previous Application Made: Yes ❑ No ?4-ii-New Construction: Yes "fd'r❑, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within :1 feet.) ' _._ - --�-------.Material----- -- ---- - -�---------------------------- Septic - - ---- Septic Tom• Distance from nearest well=_ Distance from foundation____ - No: of compartments.____ Size.(_ .dl 4-A-14-0__Liquid depth__-__A/ ---Capacity_ -v------ `- r �_'__._--.Distance to nearest lot line----ko_-- Disposal Field: Distance' from nearest well-l�- _______Distance from foundation____ �+ .. Number of lines----------- --- --------------Length of each line_---__-' - - -1---------.Width of trench__ ------------------------- -- p Total len th ! ._!_... F �_ �__._.De th of filter material_.-_-- __ Type of filter material--- . �-- 1� -- - g • .r - w 1 "Q �" `- ®:_.Distance to nearest lot line-10-.1 Seepage Pit: Distance to nearest welL.:�,__.._y--__--Distance from foundation..... .. ...... �f f Number of pits------J------ g — ----.Depth---rr w -------------•--- -------------Lining material_�+Size: Diameter______ Cesspool: Distance from nearest well--------------- -Distance from foundation--------------------Lining material-__ _._-----__------_---.__--___---_. ❑ •--• Dep#h----------------------- ---------- -------------Liquid Capacity-------,------- gals. Size: Diameter Distance from nearest well-----.---------._y---------------------------- -Distance from nearest building-----.--__._-__----.--______-------_----. nearest.ot line- - —. _ _ ------------------------------------------------- Distance to ---------- Remodeling and/or repairing.(describe):---------------------------------------------------------------------------------------------_-------------------------------------------------------- -------------------•-------------•------------I•----------------- ----------------------------------------------------------------- ----------•------=--•---'- •---------------------------•-----•---------- -------------------------------------------------------------------..--------------------------------------- ----- i hereby certify that I have prepared' this application and that the work will be done in accordance with San Joaquin County ordinances, St. a laws, and rules and regulations of the San Joaquin Local Health District. 1 i Contractor) - {Title)-- ----------------- ---------- By:------ - _ (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 4 APPLICATION ACCEPTED BY--------------------------------------------- - ---------- DATE �� ' DATE.----- ----- REVIEWEDBY------------------------------------------------------------------------------- ---------------------- - BUILDINGPERMIT ISSUED-------------------------------- -------------------------------------------------------------------------•------------ DATE-------------------------------------------------•---------- Alterations and/or recommendations:------- ----------------------------------------- •----------------------•--------------------•- ------- ---- ---- I FINAL INSPECTION BY----------------------•-----=------------------- =--=------------- � Date--- - ------- -------------- ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street !30 South American Street TracCalifornia Stockton, California Lodi, California Manteca, California y. FS-9-2M Revised W-2100 ---