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APPLICATION FOR ._ANITATION PERMIT, . Permit No. (Complete in Duplicate) Date Issued __ Ag �a�ion 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. y .. JOB ADDRESS AND LOCATION------------1-90O---S----D-------------------------------------- --------------- ---------------------------------------------------•-- Owner's Name--------`Jahn-A, D€-x'dpn--------------------------------------------------------------------------------- -- �! X6-5-------------- --------------- Phone----- - ---------- Address....................... 2m�_ ------------------------------------------ ------•----------------------------------------------.-•-------------------- ----=------------------------------------- ' Delta -------- ---------- Phone---------12b ----------- Contractor's Name -------- t Installation will serve: Residence Q Apartment House [] Commercial-0 --Trailer Court❑ Motel ❑ Other ❑ Number of living units: __1___ Number of bedrooms __>?__- Number of baths ------ Lot size __-59-._-K-20-0----------------------------------- Water Supply: Public system 9Community system [-] Private E] Depth to Water Tab1e4�%__._ ft. a Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay,`Lo m ❑4^CI y'❑ Adobe El Hardpan ❑ Previous Application Made: Yes ❑ No M New Construction: Yes ©. No ❑ 4 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----------------f___.Materi.al-_-- R____________________- exi,�Is ing No. of compartments-------------------- ----Size--..---- ------------------ ---Liquid depth------------------------1-Capacity----------------------- Disposal -----------------t -1-Capacity---------------------- Disposal Field: Distance from nearest well----_-_---------Distance from foundation-----_-------------Distance to nearest lot line----------------- exig ing Number of lines--------------------------- -----Length of each line-.-------------J-------------.Width of trench:- ---------------•---------------- Type of filter material_________________________Depth of filter material----.--_..-__� -______Total length---------------------- Seepage Pit: Distance to nearest wellno----------------- from foundation--_. ..._:.Distance to nearest lot line___5t____,_._ 21 NLimber-of,pits--.1---------------Lining mateSize:-Dia meter------------3 t..►---Depth-,-.3-0-1--------------------- Cesspool: Distance from nearest wefL________________Distance from foundation..___._.-- Lining material-------------------------------------- Q ❑ Size. Diameter--------------------------------------Depth--------•-- --------------------•---------- -- --Liquid Capacity------------------------------gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearesf building---_____ I__.______-________________._. Distance to nearest lot line________________________ ,t' ❑ ----------------- ------------------------------- r Remodeling and/or repairing (describe):---------------_ _ ------- stepagto eXiStInQ' SeT)t C} SV8te1 ___ __ - ----------------------------------------•----------- ------------------------------------- -----------------------------------------------------------------------------------------------------------•------------ ------------- I ---------------------------------- y. that 1 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. (Signed)----------------------------- - F D Cl t &. (Owner and/or Contractor) Y POW -----------------------------------------------------------------(Title)- Mgr' B : (Plot plan, showing-iie of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 'BY-------- --------------------- ------ DATE--------- -, - ie REVIEWED BY.-•----------------- `•------------ ------ Y---5 BATE ` ��f� ----------------------- - ------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------- •- --------- DATE ------------------------ Alterations and/or recommendations------------------ --------------------- ---------------•--------------------------------------•--- --------------------- ----------- -------------------------------- ------------••------------ ---------•------------------------------------------------------ ------ -----------=---------------------------------------•--•----------------•------ -------•-----------------=------------------------------------------------------------------------- --- -----------•---------------------------------------------------------------•------------ ------------------------------------ --------------------------------------------------------------------------------------------- FINAL INSPECTION BY--------------- _ Date- -2 / �`" aC`- -------------------------------------------------- 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 Revised W-2100