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APPLICATION FOR SAN // 1TATION PERMIT Permit No. (Complete in Duplicate) 0011— Date Issued Applica+ion is hereby made to the San Joaquin Local Health District for a per o construct and inst rsr herein described. This application is made in compliance with Count Ordinance o. 5 s ; JOB ADDRESS AN Lo, r--- ! - ••------------•------ -------------------------------------------------------- Owner's Name ---- ____ ? ,. ----- Address i ------•---- -•-----------•----•--------------------•-------•---------- ----- --------------- Contractor's Name {_G ------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trail r Court ❑ Motel / ❑ Other ❑ 'Number of living units: _-�___ Number of bedrooms -Y._ Number of baths -� _--_- Lot size -•-- Water Supply: Public system Coinrnunity system C] Private ❑ Depth to Water Table _�f)ft, Character of soil to a'depth of 3 feet: Sand ❑' Gravel ❑ Sandy Loam ❑ Claz y oam ❑ Clay ❑ Adobe Hardpan E]Previous Application Made: Yes E] -No Er-IN—ew Construction: Yes [:1No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Se TanDistance from nearest well_-------------------Distance from foundation________________--.Material_.______.__-.__________-_--____-_-__ ' No. of compartments-- --- Size-------------------------------- ------ • Liquid depth---------- ---------Capacity------ -- ------ • osal iel�: Distance from nearest we? .---Distance from founclation_,J _..._ -�1 Number of lines-------�- Distance to nearest lot line__.--_-__ IliGf{[>) ----Length of each line-.4Q------ Width o{ trench.__c � -------------------- Type of filter material_____ r, -Depth of filter material_____ �9.-�f r �--E� ----- Total length---•----- ---Q--•-------- ------------ Seepage Pit: Distance to nearest well_ .�"Y ,r Distant om foundation_['''`Q__(`___.Dista ce to.nearest lot line__-__�f 4 Number of pits-._./--------------Lining material___ - __----Size: Diameter._ 1 r Depth esspool: Distance from nearest well________________Distance from foundation------------------- Lining material----- --------- --------- ---------- ❑ Size: Diameter---- ------------ --------- ------Depth-------------------•--------------------------------Liquid Capacity----------------------------gals. Priv , Distance-f`rom nearest well---------------_--- - -------.-Distance from nearest building -Distance to nearest lot line- ----------------------------- ---------- ----------••-----------•---- Remodeling 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 Count ordinances, S ws, and rul5AV9WV {inns of the San Joa On Local Health District. septic Tan!t Service (Signed).... 1�A6-So:-Eldmnd-a---Ft0-Z7Cr46 --- —iG Re r Contractor) By:----------------------------------- Calif.Stockton, _ r - -- -------- (Title)--- ______ (Plot plan, showing size of lot, location of system in relation t wells, buildings, c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- - -- -- ------ DATE------ - ---- --------------------------------------------- D -------------------------------------------- ------ BUILDREVIEWED BY - ---- - -- -----------------------------------------------------•------------ DATE ' ING PERMIT ISSUED______ ________________ _ ------- DATE------------- `- ---- --------------------------- --------------•-- A Alterations and/or recommendations___________ _____ '�S" = ---------- ----_------------------------- --- -- ---- --- ------------------- -----------------A- .................._---------------------------------------------I-------------- FINAL INSPECTION BY:------------ -- ---- ------ Date_ ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak S+ree+ 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 145446 ATWDMD 12-54