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APPLICATION -FOR SAN ION PERMIT (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health District for a per[nit-to,construct and install the work herein described. This application is made in compliance with County Ord �e No..549. JOBADDRESS AND LOCATION_- - ----------- ---------------- ------------------------------------------•-----=• --- -- -------------------------------------- o hone------------------------------------ Owner's { Name-----=---- ------------------- ------ - -------------- ------------------------------- Address-------- -----------------------------Address------------f------ ------------------------------------------------------- Contractor's Name = ----- - Phone - _ Installation will serve: Residence Apartment House ❑ Coimn erciai ❑ Trailer—Cou {� Motel ❑ Other ❑ Number of living units: & Number of bedrooms Z Number of baths d Lot size___ ---------------- Water Supply: Public system p Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobex, Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer wer is available within 200 feet.) Septi Tank: Distance from nearest well__ ____Distance from f undation___�_a_______.Mat ripl___ __ __ _______ __ _ ____________. No. of compartments___.___________-_Capacity___ So-------Size_-Q_ __y ___ -____Liquid depth____-------------- Cesspool: Distance from nearest well_______----------Distance from foundation--------------------Lining material-__-_______-_____________________-_-_ [] Size: Diameter--------------------------------------Depth-----------.---------------------------------------- a Privy: Distance from nearest well---------------------------------------_---------Distance from nearest building__________._____________________-----____. ❑ Distance to nearest lot line--------------------------------------------____ Seepage Pit: Distance to nearest well----------------__-__Distance from foundation---------------------Distance to nearest lot line________-_______ ❑ Number of pits_____-----------------Lining material__________----_-_---___Size: Diameter----.------------------Depth-------------------- M Disposal Field: Distance from nearest well 00_-_____-Distance.from foundatio ___ ___ Distance.to nearest:.lotrline_ �__-_, „!„ ------ -,.. - Number of. lines__,_ter— ---_--------=_ __-Length-of-each•-Iine � '3_fD_3_*V tai of tranch__ ____________________________ of filter material__ } _---Depth of filter material__�_St) ----------- Type Ia delingand/or repairing (describe)=----------------------------------------- ------------------------------------------------------- ------------------------------------------------ ----------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Si ned =ofL - : ------------------------------------------------------------- { ) 1 - By=------------------------------------------------------------------------- .................................................(Title)---------------------------------------------------------------- ! (Plot plans, showing size of lot, location of system in relation o wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ ------------= ---------;-2----------------------------------------------------- DATE-----------�------------- �------te---�:-f---------- REVIEWEDBY---------------------------------------------------- -- - DATE------- -�- 1t f-------- - DATE------- " A- ---- BUILDING PERMIT ISSUED-------------------_------- - - -•-- r Alterations and/or recommendations_______________________________ . --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------•-----------------------------_---•-------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------•------------------------------- ---------------------------------------------------------------------------------•---------------------------------------------------------------------- ------- r ----------------------------------------------------------------------------- ----------------------------------------------•----------------------------------------------- -- -------------------- PERMIT No------------------------- ISSUED------------------------------------------(Date) FINAL INSPECTION BY:------------------ --- ----------------- Date----------------•------------------- -" '-----.-----�------- r SAN JOAQUIN LOCAL-HEALTH DISTRICT N 130 South American Street Stockton, California ES--9-2M 9-50 W-1639