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EOR ICE USE: �" Z- APPLICATION FOR^SAN ATION PERffIT Permit No. ..�. ! ...... ------------------------------------- ------ (Complete in Duplicate) _________.._._____________________________ _ This Permit Ex fres 1 Year From Date Issued bate Issued -V�E o G Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--------- 1- -0_x- �[----- Owner's Name (,��1j,_J '-C-------- ------------------------- ----------- --- -- �Phhon�,�f , ------- 1�d Address---------------- - .S Q-�....�-3�-------�`-'. - J / ------------------------- Contractor's Name----------•--- _. �'��- ----•------- ---------------------- ------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apar ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ________ Number of bedrooms ________ Number of baths _______ Lot size Water Supply: Public system ❑ Community system ❑ Private'W Depth toWaterTable ________ ft i� Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date.......... ---------) No E& New Construction: Yes §1.,,No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) k � SepticT Distance from nearest well_�'Q------Distance from foundation___/V____.__-Ma rial la _________________ W ..........No. of compartments-------.r�_ ------------Size____bl;_14- .Liquid depth___x..___ Capacity____fkl�_-0___ O Dis os field: Distance from nearest well-_-t�" _� Distance from foundation_______,,,,`, p _ ___ '`�G�--_-__-Distance to neares lot lin Number of lines_________ _' ____._ __Length of each line------- ______._ ----Width of #rench__ _, .- b"3 Type of filter material---Depth of filter material-------1 ---------Total length___.'___ ___EGD_______________ Seepage Pit: Distance to nearest well --Distance_Distance from foundation____________________Distance to nearest lot line_______________._ [❑ Number of pits----------------------Lining material-------------------,Size: Diameter-----------------------Depth------------------_.------------- 4 Cesspool: Distance from nearest well-------------_--_Distance from foundation--------------------Lining material-------- __-------------------------- Size: Diameter-------------- ---------------- ----De th------------------ ± Liquid Capacity O ❑ p q p y----------------------------gals. IE Privy: Distance from nearest well_________________________________ ______________Distance from nearest building----------.____________________________- ❑ Distance to nearest lot line-------- -------------------------------------_----------------------------------------------------- --------------------------------------- (,1 Remodeling and/or repairing (describe)-------------------------------------------------------------- -_ - A ----------------------------------------------------------- ----------------------------------------------------- -------=----------------------•-------------------------------------•------------------------- ------ -------------------------------------------------------•-----------------------•--•----------------------------------• -=-----•-----------•----------------------------------------------------------------------- ------- --- -------------•--------------------------------------------------------------------------------- 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)------------------------------------------------- ------------ -------------- ----------------------------------------------------------------------------------(Owner and/or Contractor] By------------------------------------------------------------------------------------------------------------------------------------(Title)--------------------- -----------------................... ----- " (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). [��FIlOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------�h------------- ( -------------------- DATE------------- REVIEWED BY ----------- -------------------------- ` DATE BUILDINGPERMIT ISSUED------------------------------------------ ----------------------------------------------------------- DATE--------------------------------------------- Alterations and/or recommendations------------------------------------------------------------------------------:��------------------------------------------------------------ Ae- -------------------------------------------------------- ------------------- ---------------------- ---------------------------------------------------------••------------••------------------------------------------ --••--------------------------------------------- • ------------------------------•-------------------------------------------------------------------------------------------------------------------------------------- ---------------- -------- -------------- ----------- --------------------------- -----------•----------------------------------------------- -------------------------- --------------------------- --------------------- FINAL INSPECTION BY:...:............ --- f --------------- Date s ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haseltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-S9 3M 3•'63 F.P.CD. �'