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APPLICATION FOR SA141TATION PERMIT Permit L _ (Complete in Duplicate) Date IssuedApplication is 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---- -------Wa- Owner's Name--- _1sT�3-l7G- - �^^ " f ---------------------------------------------------------------------------- Phone__ - Address a 0--f?- '�' C" At _/L� 'Contractor's Name----------------------------------------------------------=--------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence []Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ t___ Number of bedrooms .___ Number of baths __/---- Lot size __ -a4---, __ --'�- + ---------------- _ Water Supply: Public system ❑ Community system 0 Private all to Water Tabletft. Character of soil to a depth of 3 feet: Sand U Gravel I] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan 93/ Previous Application Made: Yes ❑ No X111, New Construction: Yes Z'�'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (Nb'septic'tanli of cesspool permittedTif `public sewer is available wifiiin 200 feet)- Septic Tank: Distance from nearest well----A_-b-----Distance from foundation_____LX____ Material____ --a- _ v)T No, of compartments_____:- -_____-_____Size_S�Z?-_ f4�_-,AUL__Liquid depth________________ Capacity C ----Ca acct --- Disposal Field: Distance from nearest well-----------------DisTance from foundai-ion-------------------- to nearest lot line________._-_.____ ❑ Number of lines-----------------------------------Length of each line-------------------------- .Width of french----------------------------------- Type of filter material--------------------------Depth of filter material-----------------------Total length-------------------------------------- - Seepa e Pit: Distance to nearest well___�r -- -------- - from foundation--- ---------Distance to nearest lot lineir Number of pits----�`---------------Lining Diameter-----414--V-----Depth------i--9-------------------- •� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals . rom neare"'bvildin -` " Privy: Distance from nearest well-- -__--____-__ is a g`-- ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------- -------------------------------------------- i rRemodeling and/or repairing (describe)------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. k (Signed)-- .°' ' -�" : --- - -- - —_- . _. --- ----- ------------------ ----------------------------------------- By. (Owner and/or Co trac-------------------------- ----t-o--r- - By- ---------------------------------------------------------- --------------- -------------------------(Tit!e)------------------------ (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ----- ------C ------ -------------------------=---------------------------------- DATE - REVIEWED BY DATE ` BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ Alterationsand/or recommendations-------------------------------------- --- -------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- ----------------------------------------------------------------------------------------------•-------------------------------------------- .. ----------------------------- -------------------------------------------- FINALINSPECTION B ----- - ----------------------------------------------- -- Date----- - --------- I----------------------------------------- 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 8-51 Revised W-2100