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APPLICATION FOR SA NiTATIQN PERMIT Permit No. (Complete in Duplicate) Dat () e Issued ---- r Application is hereby made to the San Joaquin,.Local Health District for a per to onstru�and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION _ -„:_---- - QJ�,� . — .. . ry Owners Name---- � .. ..---- � ��' �' ---------------------------------------------------------------' ., one ----------------------- i Address. f s _ p - ------ --------•-------------------- Contractor's Name------ ��z - / ------------------------------------ Phone___. Installation will will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑, {.e Z r ' '' 3 � r Number of living units: =,- Number of bedrooms =.1 Number. of, ths- -? _ LQt size Water Supply: Public system ❑ Community. system ❑ Private Er Depth to Water Table ! ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑_ .Clay Loam ❑ Clay ❑ Adobe [9`` Hardpan ❑ Previous Application Made: Yes El No E2/ New Construction: Yes E No E] PHA/VA: Yes ❑ No ®� 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_->, -t.�-----_Distance from ounda+ion--- ---__----.Materyal_---_i'� _�'_ % 9 - No. of compartments.---- �----------- Size_/'. `+ :_�t4i' i9�d depth i � p. Capacity-------- ---- ----- Disposal Field: ; Distance from nearest well---C�2D__--Di stance from foundation__ ist�n to nearest lot line----01 _ __ *� Number of lines--------- ---- Length of each line------- �'�”____-Widthhof trench-------=-� �---___--- t -- - -----Total length----- - ---------- Type of filter material-__-_- _Depth of filter material -- Z3 Seepage Pit: Distance to nearest well_.-- r Distance from foundation__--- '�.:: t " to nearest lot--.� mlin_e, -m"k___-/--_ ❑ Number of pits ---_---.--Lining mate r____-Size: Diaeter___ -_-r� --_-------Depthj- ------------------ Cesspool: Distance from nearest well--------_--_----Distance from foundation--------------------Lining material-------------------------------------- El Size: Diameter------------------------ ------ ------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well ------------------------------------ ------Distance ,from nearest building ---------------------------- ❑ Distance to nearest lot line____s._.__--- -- Remodeling and/or repairing describe):_---L�'S�z�`��'� ��.�!,�1- rs_r`/ �-- �¢� (fi:.�Z� � --------------- ----- y r ? f = � .- t. jr �/ i ce � �' 3 z_. ---------------------------------------------------- ---------------------------------------------------------------------- W --- ----- ------- --------- ------ ------ ------ ------ - - - ------ --- - - I hereby certify that I have prepared this application and that the work will 1e`done in accordance with San Joaquin County ordinances, State laws,-arArules and regulations of the San Joaquin Local Health District. (Signed j7 (Owner and/or Contractor) By:--------------------------------------------------------------------------- - -- - ------ -- - --- - -----------(Title)------------------------------- -------------------------------- (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY REVIEWED BY �f ,.1 ----------------- 1..- -- - - • --- DATE-------------" -�-�--`E y� L�------- A PLICATION ACCEPTED BY----------------------- ---------- - ------------- DATE-----------�-`� ,I, �� :..� , -- --------- -- ------ ---------------------- BUILDING - PER,IT --------------- AlterationsISSUED and/or recommendafions:-_.-_--- DATE - -----------------------.-.- ---_ _-_ :::----- -------------- ----- - ::, - - --------- - - ------- -�- ------ ------------------------------------ --------- ------------------ ----------------------- -- a - --- ----------- ----------- ---- -------- -------------- - ---------------- ---------- FINAL INSPECTION - " ------ - Date---- --- -^ .. 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 1-97 F.P.CO.