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PPLICATION FOR SNN[7.,r ION PERMIT Permit No. ._� ................ V : (Complete in Duplicate) x Date Issued / Application is hereby made to the 5dn'joa uin Local Health District for-a permit to construct and install the work herein described.' ' This application is madewin--ccimpliance with County Ordinances No. 549. JOB ADDRESS LOCATION---- _ _ ✓---'--------- , -AA -,�"-------------------- Owner s Name •'�' --- - ------------------------ -------------------- Phone. �, f- f Address------- �------------------------------------------------ ---- -------- ---------A----- r Contractor's Name -- ----- :. ~ phone...._.. •G - • - - ❑ Installation will serve: Residence Apartment House ❑y ommercial ❑ Tr iler Court ❑ Motel ❑ Other o '.�- Number of living units: ,._.__ N bar of bedrooms __ Number of baths _______ Lot size ._ _- -- -- Wafer Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. c Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay,Loam ❑ Clay ❑ Adobe[L�*<ardpan ❑ Previous Application Made: Yes ❑ No EKO"New Construction: Yes No ❑ PHA/VA., Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: i (No sepfic tank or'cesspool permitted if ublic sewer is available within 200 f;�� •--- In— ,Mk- � Septic Distance from nearest well_ _ S Disto ce7from�foun�ation__. _ - Mat nal No. of compartments - ------Size._____ ___ Liquid de th_ -----------Capacity--J-----d- Q Disposal Id: Distance from Weare t well l�' __Distance from foundatio _I_ -----------rDistance to nearest line__ Number of lines___ :_ ____ -r' -•-Len`fh' of each line____ g ��-� - Width of trench •- Type of filter materi I---- - ll ---Depth of Vter material____._!- _____ _Total length__.___ Q. Seepage Pit: Distance to nearest well------------_..........Distance from foundation_-..._!------ _____.Distance to nearest lot line-----_..___-___-- ❑ Number of pits.--------------------Lining material----------------------- Diameter--------------.--------Depth---_-..------------_- Cesspool: Distance from nearest well-----------------Distance from foundation----___'-----------Lining material--_______________________-__-______. El Size: Diameter_____________________ _---------------Depth-----------------=----------------------------------Li- quid Capacity_ 9 p tY -------•gals. Privy: Distance from nearest well-----------------------------------.-----------..Distance from nearest building___=_______--_- }, ❑ Distance to nearest lot lire_______ -' ---------------- ------------------------------------------------------------ --------- R� odeling and/or repairing (describe)-------------- -------------------------- = -------- -------------------------------•------------------•---------. ...... --------------•----------------- --------------------------- --- - -----------------------------------------------------•----------------------- •I--•------------=------------------------------.---------•-----------.•------- 1 hereby certify that I have prepared this application and that the work will"be done in accordance with San Joaquin County ordinances, ate laws, and rules an regulations of the San Joaquin Local Health District. . Si Wed � - ( 9 } --------------------------------- •-------------------(Owner and/or Contractor) S By:................. ............-------------------- ------------------------ ------------------------- -------------------------(Title)---------------------------------------------------------------- i (Plot plan,Aowing size of lot, location of system in relafion to wells, buildings, etc., can be placed on reverse side). -V FOR DEPARTMENT USE ONLY v APPLICATION ACCEPTED BY---------------- ------ -------- DATE-------------------------- REVIEWED BY DATE-------- BUILDING PERMIT ISSUED ----- --------------------------------•------------------------------- DATE---- Alterations and/or recommendations:—_ -------•----------------------------------------- -- -------•---------------------------•------------------------------------ -------------------------- �1------------•-- ----------------------- --------------I---------------------- - n ---- -- --------- 1 -- ------ '. �, -------- � -��,�___ _�,.��__ � -- 417^t_h1��,�l3°�-__.____A-f9ord ,�_ � l�Y'________________ _________ FINAL INSP N BY---------------------•------•-------------- Datete JOAQUIN LOCAL HEALTH DISTRICT { ti� I�t 130 outh American Street 300 West Oak Street 132 Sytamore Street 814 North "C" S+}let ! f Stockton, California C�p Lodi, California Manteca,'California Tracy, California t ES-4-2M , Revised 1.57 F.P.C� C<00- 'Oro.