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FOR OFFICE SE: Jig .L3 1/� ---- ------ -----------------------........__ APPLICATION FOR SA141TATION PERMIT Permifi"No:`/:: I-------- {Complete in Duplicate} ___________________1 .----------- a . __ . .----------------------- Date Issued ... ........... This Permit Ex fires T Year From Date Issued -•-•- 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 Coun y Ordinance No. 549. JOB ADDRESS AN OCATION...... c6- i-.-- -- _-.,---Cr.�J�� •-�/ ----------------- -----------------------• -----------•---------•----------••---••--•- Owner's Name----------- --------- Phone...............-•--- _ Address------- f Contractor's Name------- 37—S ---------------------------------------------------------------------------------------------------------- ----•--- Phone....................---................. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other`[]`~*fir= Number of living units: A____ Number of bedrooms __�_ Number of baths __-t.. Lot size --_5�.&O(J-_'k6- Water Supply: Public system , ommunity system ❑ Private ❑ Depth To Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[3--Kerdpan ❑ Previous Application Made: (If yes,date.___'_______________) No New Cohstruction:-Yes. No ❑ FHA/VA: Yes ❑ No [� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permiffed if public sewer is available within 200 feet.) + Septic Tank: Distance from nearest well_____' ______Distance from foundation/_Q._-______._..Material__1C-{ ur -_---- r ¢ ®� No. of compartments-------- --------.._Size.... _ i.' `�-,_--Liquid depth---•• ------- Capacity.._ _ Disposal Field: Distance from nearest well.......... .......Distance from foundation._/P__r.......Distance to nearest lot ❑� Number of lines--_'= =--r-------------------Length of each line....90__-7f---60.Width of trench.-- - ---`------••---------.. Type of filter material.` _C_-� -.-_:Depth of filter material 21-t--"---""_Total length_____/4_--OP.' f Seepage-,Fit: Distance to nearest well______________-_____Distance from foundation____!__.1?..e._._-Distance to nearest lot Iine...45l...... ,y -- L� Number of pits-----2,---------Lining material__ -��(----Size: Diameter_�....`--..._._Depth__ ---.-----•------ Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material_-_.__-___•.-__._______---_.--___._-. ❑ Size: Diameter___________________________ ---------._Depth--------- ---------------------- -----------------Liquid Capacity------------=---------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building-----------.._______-_--•_ Distance to nearest lot line___________ Remodeling and/or repairing (describe)------------------------------------------------------ a ------------•-------- --•---------------------------------------------------------------------•--------------------•-----------------------•------._....-----------------------•---------•-..__..--------•--- ------ I hereby certify -------- 'Jot, hav prep ed this application and +hat the work will be done in accordance with San Joaquin County ordinances, State laws, and r s an regulati ns of +he San Joaquin Local Health District. (Signed) -------------(Owns a�/or Contractor) € By:-- -------------- - ----••---------------------- ----- ------- ----------(Title) (Plot plan, showing 'ze ot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ! APPLICATION ACCEPTED BY_.Z,/_ .-✓------------------•------------•-- DATE.- ` --- '=- ------------------ REVIEWI=D BY ------------ - --------------------------------------------------------------------•---------._.. DATE---•--------- BUILDING PERMIT ISSUED------------------------------------- ----------------------------------------------••--------------- DATE...-----------------• - Alterations and/or recommend'a+ions:---------------------------_-__- - --•------------------ - ---------- R---••------------------------------ ................... ---------------- -------------------------------- J---- - - . ��-�.3 - --- r - cza---------------------_-- -------------------------------- -------------------------------------- FINAL INSPECTION BY:.---- - u' ----------------•--•---------------- Date------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 Wu 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED B-59 2M 5-62 ATLAS