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FOR OFFICE USE: -- ell -------- APPLICATION FOR. SAMATION PERMIT Permit No- ill ` I ---- (Complete in Duplicate) I ` - This Permit Expires 1 Year From Date Issued Date Issued Application 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 Ordinance No. 549. JOB ADDRESS AN LOCATION_/9I/� .�!- grr�•._?L{J�. 'L- - - OwnersName.------ r-- ---•-----•--••--------------------•------------------ -----------.... Phone--------------------------------•--- e Address---------------=1.6.6/---- ---- ------ = 0 Contractor's Name------- - ---- ------------ ---- ------------------------ --------•-------- Phone---�.1�_ - !0- Installation will serve: Residence Ell Apartment House 0 Commercial ❑ TrailerCourt ❑ Motel ❑ Other ❑ ` Number of living units: ---,L- Number of bedrooms____ Number of baths __ LOT size ----lelt_�_____________________________________ Water Supply: Public system ❑ Community system ❑ Private [ Depth .to Water Table -------- ft. Character of soil to a depth of 3 feet: ?and ❑ Gravel ❑ Sandy' Loam ❑ Clay Loam Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date----.____.._..,----_---) No•RT""New Construction: Yes No ❑ VA; Yes ®'- No ❑, TYPE OF INSTALLATION AND SPECIFICATI NSc' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest well----'�� Distance from foundation------f_0--- Material_...____.____--_______..�_�________________ No. of compartments------y._------.---SizedX`4_l .�r_Liquid depth_....__ ...._-------Capacity Se7o_- { Dispos Field: Distance from nearest well... -----Distance from foundation---/.P--- ----- Distance to nearest lot line'1r"___�-________ F' P Number of lines___.____________________Length of,each line-------7S...............Width of trench_. a--_�- Type of filter materia!-___- ---------Depth of filter material ___._-/_9....__...... otah. length...... _ -_._ ________ _____ Seepage Pit: Distance to nearest well__�UU_- _ Distance from foundation___PU-+-___ Distance to nearbst lot line--.- Number __ 3 ® p ----------Linin material----�XY_�.--_ of its----- 2,>_*"-- -.De tn-----a-�l------------------ g �-'� Sze: Diameter _- p Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining ❑ `� material-______...__-_._____._______-_______- Srze: Diameter-------------------------- ------- -_De th------------- _------ - - - ------Li Liquid Capacity ---- - ---------._gals. Privy: Distance from nearest well---------------------_----___----------------------Distance from nearest building------------------------------._-_-..----- ❑- Distance to nearest lot line- --- -----•------ ---------------- --------- -------- - Remodelingand/or repairing {describe}=------ -- ---------------------------Z---------------------------------------------------------------------------------------------- ---------------`'-.. ---------------------------------------•- ------------------------------------------------------------------ -------------------------------------------------------------•------------------ ------------------ --- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I and rules and r;ofiystern ons of the San Joaquin Local Health District. 'Q; Si ned _ ran _. .._. g }=__ == — .. r- e 4d/oContractor} - �s _By:-------- - ---- - k------ --- -------------.-----------------------------(Title)----------- ------------------------------- ------------------ (Plot plan, showing size of lot, location in re ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY... .. .----- ---G` iJ---------------- ---------------- DATE--------- REVIEWEDBY------------------------- ----- -------- -----------------------------------------------------------------------------• DATE-------------- ------ BUILDING PERMIT ISSUED-------------------------------------------------------------- ----------------------------------- DATE--------------------- - ------------------------------------------------- ----- --------------------- - Alterationsand/or recommendations:------------------------------ ---- - - -------------------------------------------------------•-•----•-----.-.-------------------------------------.-_- ------------ -•----------------•--------- -------------•-----•------•---- ------ ------------ ----------------- ---------------------------- --------------------- ----------------------------- ------ i --------------------------___--------------------_____________________ .. FINAL INSPECTION BY:........`� ...... ------- Date-- --- - L p `j------ --- ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E.Ha=ellon Ave. 300 West Oak Street 724 Sycamore Street 205 W9—sF9fh Str:L_eet ' Stockton,California Lodi,California Manteca,California Tracy,California