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APPLICATION FQ �1 R SANITATION PERMIT Permit No. ---_ (Complete in Duplicate) 3/ Date Issued 1. .I pplication.is hereby made to the San Joaquin Local Health District for a permit to construct and install fhe work herein described. n{N Tis applicafion is made in compliance with County Ordinance-No. 49. .. JOB ADDRESS AND R ,. .. . . L.O7 �A) ._ ------------------------------------------, c'. •---------- -;- --t +Owner's Name . .. --------- - ------------ - - PhoneAddress_ • . — i __ „ u A -- - --------,----- Contractor's Name J -------- - - -----�--- 11� -�--'---�' Phone. ------"---•--Installa+ion •----...--- will serve: Residencep to arfiment House❑ +Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of livinguni#s •-i. - f , ."__ Number of bedrooms . _ Number of,l3aths '__:_ Lot size""__ ____ " �f�..............Wafer Supply: 'Public.system [ Commun'it s stem '� ;� f S � i y y ❑ Private'0 Depth_ to'Water Table -��_-_es/°`{#; "�-• -. Character of soil to a depth of 3 feet: Sand Gravel a ❑ ❑ Sand Loam F ❑ • Adobe Hardpan ❑ � yam, ❑•..,Clay Loam ❑....ClCla Previous Application Made: Yes.❑'.-No ( few Construction: Y_es ❑ Ngo-[� 'l"NA%VA#Yes [] No [] TYPE OF-INSTALLATION AND SPECIFICATIONS: (No septic tankor cesspool permitted if public sewer.is available within 200 feet.) } Septic Tank: Distance from ' "` `F s- --�•. - ._.- om nearest well__ istance f from/-foundafion____ _ Material -(�. No. of compartments_". -_-"_- '""_ Size_f fill__ "C7__Liquid depth__- 4 i - - j� � -- .Capaci ---- Disposal Field; Distance from nearest well. _ �sta}Ice from foundation-_ • ---�_-_.._.Disfiance to nearest I t line �, Number of lines" °.� g of each line----- ' i--PA Width of trench___-�,�- Type of filter material 1-;�epfh of.filter material--__ /` f L ` ti f Total length -----------• -- p g P M...y .: ' t �. ----- Seepage Pit: Daee.o i a est well--__ -_LI�67[� --Distance�3; fou anon- rf-'�._":_..DistaC;�e to nearest lot line__ ----- Numb u. . g materia -- -•Size:A piameter_ _ _ _-•. --.Depth----- Cesspool`: Distance from nearest well----}...... Distance from foundation_"""_.'______,_. .Linin --- - material_-_ ❑ Size: Diameter--'--- =-- Depth c ` .- LiquidtCapacity- gals. l rivy: Distance from nearest well ----" -- _--,_--_--Distance from nearest buildin ❑ " - Distance to nearest-lot-lined -------------- "4"" --------------- ------------ g - Rem{delin and errepirrang (descriLe):=_w____ ' .•• --- - ---- --------•----- -- ---- - ------------- . -------------------------------- -••-- f _ ----------- -------------- ----------------------- - -----•--- -----------------------------------------------=--------••--- •------- - ------------------ ------------------ - I hereby certify that l have•prepa�ed;+his=application and that the work will-be done in accordance with San Joaquin County ordinances, State laws, and rules and 'regul tions of the San Joaquin Lo I Health District. (Signed)-------------- , ----------------------- u sy:.. - :._ - -- ------------ -- - . -- ------- ------ ------- ----- c+ Contra or) - --- .----(Title)--- ( P g Plot plan, showing size of lot, atian of s stem'in relation to wells, buildings, etc.; can be placed on reverse e. A i FOR DEPARTMENT USE ONLY' �v APPLICATION ACCEPTED BY--' r 1 ------------------- DATE- REVIEWED i REVIEWED BY-------•- K '. ---- -- --- DATE ----- BUILDING PERMIT ISSUED--------= '= = - -- ---------------------------------------- DATE------- • •-- Alterations and/or recommendations:-#'_________ __ -------- --- -------------- - ----------- ------------ - i ------------------- r4�3 �--------•---- -----•---•-------•--•-----------"---=--•- --" ----- ------------------ ••----- -- ---------•-----.- i� -------•-- - -- ------------------------------------------------------------ - ------------- FINAL 1NSPECTION BY:- ------------------------�---- Date-- =------�--'� --- .. --------------- N' " -^. --.•-.._:,. 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_P.CO.