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1-UKUFFICE USE: ----------------------------------- - ---------- ./INI, ------- --------------------- -- --------------- -------- APPLICATION FOR SANWATION PERMIT Permit No. /A&/1 ,.7 ----------------- ------------------ ---------- (Complete in Duplicate) --- ---- ----------------- ---------- --- ---- This Permit Expires I Year From Date Issued Date Issued A/. 0 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, T ):u� 797. JOB ADDRESS AND LOCATION- ZXA ------------ --------- Owner's Name ----kk -- -----------%,, -------- -------------------------------------- ----------------- ----------------- Phone-------------------------- Address ------------------- !elf�4.-—A e2n 7 _;6 -------------------------------- ------------------- --------------------------------------- Contractor's Name--,.,----- ---------------------------------------------------------------------------------------------------------------------- Phone----—----------- Instaliation will serve: Residence' C]T Apartment House E] Commercial �[ Trailer Court Ejr Motel E] Other El Number of living units: -------- Number of bedrooms -------- Number of baths Lot size --- Wafer Supply: Public system El Community system [] Private W Depth to Water Table Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam [N Clay Loam E] Clay E] Adobe E] Hardpa':n 0 Previous Application Made: jIf yes,date-- -----------------) No ❑ New Construction: Yes E] No E] PHA/VA: Yes F No TYPE OF INSTALLATION AND SPECIFICATIONS: II (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_nt0_'t__Distance from-f0 ndation---Z4---------Maferlal.__4� ----------- No. of comparfmenfs_._,�L -------- Liquid depth----- ----------- ---Ca acify--- ------- D;sposal Field: Distance from nearest wed..!:�:'2_'-f-.._Distance from foundation-----1-47--7 Distance to nearest lot line.-- Number of lines--------------------- ---------—Length of each line---- ------------------WidthN It - - of french----;L-Y 11 Z Type of filter mate rial-A144--ff ---Depth of filter material---- length-_R�?----------------- Seepage Pit: Distance to nearest well_.-_____"---____ :__Distam�e from foundation---------------.--. Distance to nearest lot line_.-.__-__""---__ ❑ Number of pifs.-!------------------Lining material--------- -------Size: Diameter------------ -------_Depth--------- ----------- Cesspool: Distance from nearest well-----------------Distance from foundation--- -------- ----_Lining material__._"---."_-"."--_ _""-"--------------------------------------I 0Sfze: Diameter----I---------------- ----------.----.Depth-.,-------------------------------------------------Liquid Capacity----------------------------gals��_ Privy: Distance from nearest well-------------------------------- ---------------Distance from nearest building--------------------------- 10 r7l Distance to nearest lot line-_------------------------------------------- I 1 ---------- 14 Remodeling and/or repairing (describe):--------- ------------------------------------------------------------ ------------------------------ --- ---- - �� I ,• ------------------------------------- ------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------7-1--- ---------------------------------- t------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------- --------- ---------------------------------------------------------------------------------------------------------------------------I-------------------------------------------------------------------- ------- I hereby certify fhat'l have pre red 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 - -- ------ - Contra for) 77 -— ----- --------�(------- ----- ----------- .... .. ---------- ----- ----- ----------------------------------- -------------(Title)------------------- ---------- ---- ---------------- (Plot plan, s owing si �of lot, liocati' f system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ------------------------------ ------------------------- DATE----q- `—----- ----- REVIEWED BY-------4o4lA f - ju/------------------------- -------------------------------------------------------------------------------- DATE---------------- ------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE--------------------------- ---- Alterations and/or recommendations:------...__ -------------------- iv -------------:....... . ----------------------------------------------------------------------------------------------------------- ------------ -----------------1----------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------- -----------------------I----------------- --------------------- --- -------------------------------------- ---------- ------------------------ --------------------------------------- --------------------- --------------------------- ---------- ---------------------------- ------- ----------------------------------------------------I------------------------------------ - -------------------------------- - ---------------- - ---------------------- ------------------------------------- --------------------------- ---------------------------------- -------------------- --------------------- --------------------------- FINAL INSPECTION BY:........ ----------- - Date----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Harellar;Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street IE Stockton,California Lodi,California Manteca,California Tracy,California F.P.r[3.