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FOR OFFICE USE: ;IM: ---------------------------------- - APPLICATION FOR-`SANOATION PERMIT Permit No. I[I (Complete in Duplicate) ------- --A------ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby madie 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, II JOB ADDRESS ANDGATION_/IF34�---- ------------------------------------------------ i Owner's Name i1 ------- ---- ---------••---------------------------- --------------------5-------- -------- Phone------------------------------------ Address--------r•�? t Contractor's Name-------41. -'r Q- - Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ tTrailer Court ❑ Motel ❑ Other ❑ Number of living un'ts: Number of bedrooms _._ Number of baths `__. Lot size _� "X.42o; _�--------------------------- Water Supply: Public system 111--Zommunity system ❑ Private ❑ Depth to Water Table 4_5�?_ ft. - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe®-'-Hardpan ❑ Previous Application Madel [If yes,date_______________ _._I No 2' New Construction: Yes ❑ No � FHA/VA: Yes ❑ No TYPE OF INSTALLATIONIJAND SPECIFICATIONS: s ' ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: _ Distance from nearest well-----------------Distance from-foundation--------------------Material---- _ ______________ ____._____________________- 91, Z//,k1(, No. 0f;tompartments--------------------------Size------------------'-------- -----Liquid ��depth--------------------- ----Capacity----------------------- :11 Field,:. Distancle from nearest well ___..__Distance from foundation._ ---------Distance to nearest lot line_.2 --- �ih Numbed of lines--------/�---------------______.Length of each line__/._--______..___-_--Width of trench. _--______.____-__.--- _--- --------------------- Type _. _ L T e of filter material 7 yp i ,�/ I�L� Depth of filter material__ ._________Total length---- Seepage ength___ ____________________ f � Seepage Pit: Distance to nearest well-___-_--______Distance from foundation_$Z_�....___Distance to nearest lot iine_,.�1J------ W II p Lining material_ �e�-Size: Dim aim,Diameter_ /,;,......De thl- r __ 6 Number of its----- -------------- P � Cesspool: Distane�e from nearest well ________________Distance from foundation-_:�.---------._- Lining❑ material-------------------------------------Size: Diameter---------------------------- - -------Depth P ----- - - Liquid Capacity gals. Privy: Distance from nearest well-----------------______________________________Distance from nearest building------------------------------------------ O I F1Distance to nearest lot line_________________ - - -� -,- KK-+ - {► and/or repairing fdescribe):----- - --------GGGl'L�r�YY�- -------- Remodeling --------------- ---- -�� ----.-------------------------------------------------------------- ------ ------------------------------------------------------------- ------ ----------------------------------------------- �!-------- ----- ° ------------------------ -------------------- =---------------------- ------------------------------------------------------------ I hereby certify that lthave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and`rules and regulati ns of the San Joaquin Local Health District, (Si ned i g ) ----- -- By: ( Contractor( By:---------------------------• I�--------------- ----------- L�a�� --- .__. (Title --- -------------------- -- ------ -------- (Plot plan, showing size of lot, location of syste ' relation to wells, buildings, etc., can be placed on reverse side). 0 1 'I OR DEPARTMENT USE ONLY } APPLICATION ACCEPTE61BY------- -- ----- - - ---- -------------------------------------------- DATE------- ---- = REVIEWED BY- - �l ---------- --------------- ------ ----- -—- - I DATE BUILDING PERMIT ISSUED---------- --- - ----------------------------- DATE---- --------------------- -- -------------------------------------------------- ' Iterations and/or recommen ations:___._. - - - ------------------------ --- ---- ----- - ------------------- ----------------------- l = . - ------- --- ----•------------------------------ ---------------- ------------ ---- t ------------------------- FINAL INSPECTION BYc----- -- -- ---- - - - --------------- - Date-------j�� =� = - S J UIN LOCAL HEALTH DISTRICT 4 1601 E.Haxellon Ave.. 300 West oak Street 124 Sycamore Street I Y 205 West 9th Street I Stockton,California Lodi,California Manteca,California Tracy,California A� r ip