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APPLICATION FOR 5ANI7A7iON PERMIT 0 ' /Q�J (Complete in Duplicate) Application is hereby made to the San Joaquin Local-Health District for a permit to construct and install the work herein described. E This:application is made in compliance with County Ordinance No. 549. ��,J ESS AND LOCATION r C,-ZAW ------------------------------------------------------ JOB ADDR Owner's Name_.------6"----K -----�--�Y -- -- +------------------- Phone----- � ,---------------- f t � t_ rC / ------ ,----------- ----------------------------------------------- Address 1A` Contractor's Name------------ --------=-------------------------------------------------------------- Phone------- ..----------- Installation will serve: Residence �, Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel .❑ Other ❑ Number of living units: m Number of bedrooms P Number of baths Eh Lot size____ ----Y-J---___)__________________________ Water Supply: Public system [g,. Community system ❑ Private ❑ r r Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or.cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-__/ -___Distance from foundation_______1.P_______.Material____.. No. of compartments------ : Capacity__�_- ---------Size___.....�� _---_A� -liquid depth_________�---:1 ____ -Ces pool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------------------_____. 1� ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- f'Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-____-______-___--_-_-_-__-_-______- ❑ Distance to nearest lot iine------------------------------------------------ � Seepage Pit: Distance to nearest well----------------------Distance from foundation__________________Distance to nearest lot line_____--.. + ❑ Number of pits----------------------Lining material--------------.--------Size: Diameter------------------------Depth---------------------- .Disposal Field: Distance from nearest well__)V--'_____.Distance from foundation----1V�_--____-Distance to nearest lot line___` i FUr Number of lines_______ ______________________Length of each line____________ �____1______.Width of trench-------�r�.____._. Type of filter material_____? _ _.___Depth of filter material_____I _!________ 110 4N�li#�lµ�lG Remodeling and/or repairing (describe)_____________ - ---------------------•-------------------•---------------------------;---------------------------•--------- ----------------------------------------------------------------------------------------------- -----------•----------------------------------- - - -------------------------- 1066 011 J , 'anus ----------------------------------------------------------------------------------- -._ 9 '9�d hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun'vl-j lb ordinances, State laws, and rules and regulations of the San Joaquin Loca_1 Health District. ' __ (signed) : --- ---------------------- {Owner and/or Contractor) BY:------------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- _ _ ____ DATE--- t?--- ----—------------ REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE--- -------- --- BUILDINGPERMIT ISSUED-------------------------------------------------------------- ------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations----------------------------------- --- _----------------------------------------•-----------------------..._.._------------------------------------------ s I-----------------------------------------------------------------------------------------------•-----------•--------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------•---------------------------------------------------- ------ - ----------------------------------------------------------------- -- ----------------------•- PERMIT NoO_0_3---7- ISSUED----- �--3_ - - ------------------------------ 9 -- / (Date) FINAL INSPECTION BY:______ ------- - - ------- -------- Date----------- ------Date----------- --"- `./"-- ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639