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APPLICATION FOR SAWATION PERMIT Permit No. L I (Complete in Duplicate) 'I 4 Date Issued Applica+ion is hereby made to the San Joaquin Local Health District for a permit folconstruct and install the work herein described. This application is made in compliance with County Ordinance No. 5:4:9. / ,, JOB ADDRESS AND L ATION - 1 ---•, 40� ` 7_'-.' --------------------------------------------------------------------------- Owner's Name--------------- ., C---'-"--- � = -------------= Phone. Address------------------------- ---- --- ---- _ --------------------------------------------------------------- --------------------------------------------- Contractor's Name ---------------- Phone------------------ - Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.I_Flumber of bedrooms .Y__ Number of baths ._ - Lot size -------------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table _�%'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No E�— New Construction: Yes ❑ No E-- "V 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------------------Material. ._. ___ _.... ._ ` -- ------- -------------- Size'. - No. of compartments -._ --------------------------------Liquid depth--------------------------Capacity--------------------- Disposal Field Distance from nearest well_�f"7 Distance from foundation_�,rr��. ;p 7Co---------Distance to nearest lot line__ t Number ort lines_ .__.__ __._Length of each line-------_.�"�t�. r�_..-.Width of trench.._ -01_y ` _ Type or filter materi " �,,._Depth of filter material----------- _ _ --------Total length _______� g , Seepage Pit: Distance to nearest well-----_--------_-------Distance from foundation_-_______-_________.Distance to nearest lot line_--__-.-______--_ ❑ Number of pits---------------------Lining material----------------------Size: Diameter------•---------------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)---------------4!7--=- --------------------------------------------- ------------------------------------------------------------------------•---•--•----------------•- -----•-----------------------------------•---------------•--•-----------------------•--------------I-------------------------------------------------------------------------------------------------------- I hereby certify that I 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) J� - -- `(1�te ..._ By:---------------------------•-------------•-- - . - Tale (Plot plan, showing size of lot, Iota ' of system in relation to wells, buildings, etc., can be placed on revers ide). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY, -- - ------------------. DATE''JA �. REVIEWED BY ----------------------------- ------------------�-- BUILDING PERMIT ISSUED--------- '' , Alterations and/or recommendations------------ -------- --------------------------------------------------------- DATE------ ------------------------------ --------------------------------------------------------•------ --------------------------- ------------- - --- --------------- FINAL INSPECTION BY:.. �r ___ 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 Traey, California ES-9-21M 145446 ATWOOD 12-54