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APPLICATION FOR $ANITAT6N, PERMIT Permit No. ` t14 (h 1 (Complete in Duplicate) /� or I Date Issued ------___'-Z --,� . Application is'h'e eby made.to"the.San Joaquin Local Health District for a permit to construct and install the work herein described. s `fThis application is made yi� omp''lign with County Ordinance No.,`549. JOB ADDRESS AND OCATIONA-- ..% Owner's Name - --------- ------- --- ------ - ----- - -------- --- ---- --------------------------- Phone ' Addressa2-d ' ------------ Contractor's N e__ <_ �' r ------ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ { V�Number of living units: _1_- Number of bedrooms __t___- Number of baths J__ Lot size ----$, _ _ QQ_________________________ Water Supply: Public system ❑ Community system ❑ Private's ' Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand [I---Gravel ❑--Sandy Loam Clay„Loam ❑ Clay ❑ Adobew Hardpan ❑ Previous Application Made: Yes ❑ Nox New Construction: Yes , No E] FPA/VA: Yes [2No� TYPE OF INSTALLATION AND SPECIFICATIONS: .6 E (No septic tank or'cesspool permitted if public sewer is available within Ll.fgett, f F Septic Tank: Distance from nearest wel#__ d____--Distarce from foundatxan _ _ __.Material______- No. of compartments----�f -----.------.---Size----V.X_6 ___.-- sLiqui depth----- ----------------Capacity----f470!------ Disposal Field: Distance from nearest—wA.__-e-.._____:Distane�from foundation _ -s _-_.Distance to nearest lot line _ T Number of lines_____ Length of each lined�.� � Width of trench _.rea _ -----__---_. f T ..e.of filter materia De #th of filter mat'ic �"_____Total length_____- Seepa e Pit: Dis#ante to nearest well_. �4 Distance from dation_ Distance to nearest lot line__ z .. Number of pits_._.__-_---_____--Lining materia _ _Size: Dia eter___� r___._ Depth..___�.✓��______________ �y Cesspool: Distance from newest well-----------------Distance from ' '** "`Priv❑y: foundation___-___-______.___..Lining material__-.,-_.________________________ _:___. (d Size: Diameter-------______________--_ D;W;h Jf_- a ___Liquid Ca acitY__— ---------gals.----------- --- ------------ Distance frorrnearest well------------------- ---- ---- /---..Distancebuilding 1I from nearest buildin ❑ Distance to nearest lot line________ r ------------------------- ReJelin and or re airin (describe):- ------------------------------------------------------------- :' - --- ------------------------------------------------------------------------r -------------------------------------------------------•----------3---------------------------------------141--------------------------------------------:.--------------,--=------------------------------------------ I hereby certify that I have prepared this application and4 '4,l the work will be done in accordance with San Joaquin County ! ordinances, State laws a rules an re lations of +h 1San.J quin Lo al Health District. ; ti (Signed),- r ----- ------- -- - --------7/----------- -------- ------.(Owne nd/or Contractor) By:_--------- - -- ----•- . j ------:--------------------- -------------------- {Title} --- - - ---- Ti -- = (Plo+ plan, s g si of to , a ion o system in relation to wells, buildings, etc., can be pace` d n ever side). f FOR,01DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ' =--------------- ---- '---------- --------------------------------------------- DATE-------------- REVIEWED BY - } ------------------------ --------- DATE-------- BUILDING PERMIT ISSUED---------------------A - '- ----------------------------------------------------' DATE- Alterations and/or recommendations:---�---- ----' ------------------------------------•------------------------ --�----=------------------------- ' �, a, &O, --------------- -----------3-r --------------- ------- ------------------- -- ------- P �-. �-,� L --------------------------------------------------------------- ----- ------------------------------ ------------------------------------------------------------------------- --------- ^' Date } FINAL INSPECTION BY: �a.=.� _ J-�---------- 0 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-9-21x1 Revisea 3.57 F-P.CO. y i