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OR OFFICE USE: - T__ -S_ _ ------- -_ _ _ /.'3-� APPLICATION FOR SAMITATION PERMIT Permit No. ...f..�1j�... - -- - -------------------------- ------- --------- (Complete in Duplicate) g( This Permit Expires 1 Year From Date Issued Date Issued ___.. . ._. .� Appl°ation 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 Ordina ce No. 549. JOB ADDRESS AND LOCATION-, --•- /_------ -- ------------- `-•--••---��_------------------- < ------------`----- --- r // Owner's Name �� r / QYLG/L-r.------------------------------------------ Phone--------a� LP_�P------ Address.../f,- ----- JfQ, y,,, �~ Contractor's Name � � `-� Phone (d' �_3l�� Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer ,Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of bath sa-!�ze . Water Supply: Public system ❑ Community system ❑ Private ' Depth to Water TablW-S-ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ Previous Application Made: (If yes,date--------------------) Noy New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sep^tic�T k: Distance from nearest wel�f�Q - -- _ _ Distanye from foundation_- __r_--.Material -------------------� Y_ p� ___ Lam' No. of compartments- ciZ._.____ Size�_,ii:._,�� Liquid de th___,$�___.____._____Ca acit /0-67a Dis osal F' Id: Distance from neares wel�Qj�_.-._Distance from foundation..,r�__-..----Distance to nearest lot line_''fi____._.___ p Number of lines------ _ .__-__ __Length of each line/�__'____ ti__-Width of trench-------.�_ _��___._._.__ Type of filter material__ -Depth of filter material___ ----------Total length------ l�Zt_---_________________ Seepaget -t-_Distance m fdatio - Distance to nearest lot line___ __... \ Distance to nearest well___ ____ n ........ Number of pits____ _____________Lining material-_ .u_.__ ___Size: Diameter---_._3� it - -- ----- ----.Depth--:-- ----------------- Cesspool: Distance from nearest well-----------.---._Distance from foundation--------------------Lining material------.--------------._--_--_--- - ❑ Size: Diameter------------------------------------Depth----------------- ---------------------------------Liquid Capacity----------------------------gals. Privy: Distance from 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 County ordinances, to la s, and rules and 7gulations of the an Joaquin Local Health District. (Signed)----------------------- -- ------- ---- ----- ------------ --------------------------------- --------(Owner and/or Contractor) BY:-------------------------------------------------------- -- -- ----- ---------- -------- ---- Title (Plot plan, showing size of lot, location of system in relation to wells, ildings, etc., can be placed o reverse side). �,�� FOR DEPARTMENT USE ONLY _ APPLICATION ACCEPTED BY---- -----sem - ---------------------------------- ------------------------------------- DATE---------��- -----�------------------------------- REVIEWED BY---------------------------------------------------------- ------------------------------------------------------------------ DATE------ BUILDING PERMIT ISSUED---------------------------------- ----------------------------------- --- DATE----- Alterations and/or recommendations:------- J� . ----------------------------------------------- --------- �` -1 ' `''� �j �� ---_----------- --------------------------------------------- ------�... 1 .�__ --------==-=----- ----------------------------- ---------------------•----------------------• FINAL INSPECTION BY:_........._; - ---------- Date.-..._______-- -- ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 Wesf9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.