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c X-r 1-OR ONCE USE: ` ----------- -- -------------------- ------_-..--_--- APPLICATION EOK-SAMTATION PERMIT Permit No. ._��z --------- --- --"------'-------------------- ------- (Complete•in—Duplicate) ----- - ------------ --- This Permit ExlRires 1 Year From Date Issued 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 County Ordinance No. 549. s JOB ADDRESS D LOCATIO -d r Owner's Name _� # = P Phone --- _Address---- •------•-- --------------- fO la Contractor's Name/ .... - . --- --------- ------------------------------... Phone--------------••-------•- Installation will serve: Residence Apartment House ❑ Commercial ❑ - Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/___ Number of bedrooms 3__ Number of baths. _ Lot size .� � . _ - ' --- -/�-fit-Res-- •------ --' Water Supply: Public system ElCommunity system [IPrivate X Depth to Water Table -7,0'- ff Character of soil to a depth of 3 feet- Sand E] Gravel ElSandy Loam ElClay Loam [:] Clay ® Adobe ❑ Hardpan ❑�� Previous Application Made: (if yes,date__...._ J No �' New Construction: Yes ❑ No ® FHA/VA. Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I Septic Tank: {Distance from nearest well-.----------------Distance from❑ foundation__..__-.--_...___.Material __...__.__.__-...._____._ I ------------------ No. of compartments--- " .....--Size-------------:------ -----------Liquid depth-------- ------ ------..Capacity----------------------- Disposal Field: Distance from nearest well.A7e'__._Distance from foundation--- _` Distance to nearest lot ® Number of lines --------/-------- --------r---�----Length of each line-. ._... .Q'----------Width of trench----- _y"'__._._______. ' Type of filter material_-�U_ `..---Depth of filter material..../6r.. 1 r ---- Total length---'-- ..�.-------•------•-----------' Seepage Pit: Distance to nearest well... -.-_-__Distant rom.foundation_,/ -____-.Distance to nearest lot line-A5_'__. { Number of pits--- '- -----.----.--Lining material_ _bMG ---- Size: Diarneter-3,�!r----------Depth_-,Z'5__ Cesspool: Distance from nearest well _______________ Distance from foundation-...__------------------ ..Lining ❑ Size: Diameter- '- -- -'--- --'-- --- '..........Depth---- ---------------r---- - -'-' -------- ...Liquid Capacity- ------------ -------------gal Privy: Distance from nearest well------ . ..Distance from nearest building ❑ Distance to nearest lot line __ ________________ Remodeling and/or repairing (describe):------./Y /_j`�lQd7--------- 'Q=- jy�j _ 1 IC--'-----, - ------•-------------- - --------------------•----------------------------------------------------------••------ -- ' ---------- --------- --------------------------------------------------------- ----------- ---------------•----------------------------- ------------------------------------------------------ ' 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. P (Signed) - �� /a �ter'rt� ------------------- -------• ----- ---- Owner and/or Contraf ctor)BY: ------- ----------------- -----------------(Title-- --------:.... -------- -- -- ---------------(Plot ` plan, showing size of lot,.location of system in relation to wells, buildings, etc., can be placed on reverse side). - T FOR DEPARTMENT USE ONLY s APPLICATION ACCEPTED BY___..._._- ---________- --__-- DATE..___..f --:��` -- ---t ------------------ --------------------- i t REVIEWED BY. ----------------- ----- DATE -- -- - -----"- --'-'-------------'----- --------------- - BUILDING PERMIT ISSUED-------- ----------- ---- -----'----- ---------'-'-- - ----------- ------'--'--- - --------------- DATE------ Alterations and/or recommendations:-----------______.-_ --------------- --------_----- ------ ----- ------' � ----- ------ - - ' -------- --- -------- ---- ____ - .._-__-_ ------......__.----------------------- FINAL INSPECTION BY:. Date------------ SAN ---- -----SAN J OAQUIN LOCAL HEALTH DISTRICT _ 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi. California Manteca,California Tracy,California EM,9 2M 1.67 Vanguard Press i ^� r