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FOR OFFICE USE: �� =---------------l13. Q-A----- p I ----- ------ ---- --__------ APPLICATION FOR SAiVITATiON PERMIT Permit No. -If T$. ' ------------------ [Complete in-Duplicate) "' This Permit Expires I Year From Date Issued bate Issued f - -.................- _. Application is hereby made t the San Joaq Local Healt Dis*ict f a permit to construct and install the work herein described. This application is madeyq r, mplie� with ty i o JOc / , �bRE55 AND LOCATION---- ---- - -------------- ------- -----•=------- - --...------------ � S - Owner's Name------ ---------- ---- -- - '-`► LL� --------- -------- Phone-------------------------------- Address -------------------- y Z 4 - = -- iContractor's Name---� "' ----------------- -` `- _--.--- I - `-?'a-----`-�-- -------------------= - Phone.. Installation will serve: Residence 0- Apartment House ❑ ,tmmercial ❑ Trailer Court❑ Motel ❑ Other ❑ Number of Living units: __ _._ Number of bedrooms _-j___'Number of baths _._ Lot-size--------________________________________._________________ Water Supply: Public,system Ems''Community system ❑ Private.❑ Depth to Water Table,3Q ft. Character of'soil to a dep't�h�of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑. Clay Loam ❑ Clay ❑ Adobe E]-"'-Hardpan ❑ Previous Application Made:'(If yes,date--------- -------- -1 No e New Construction: Yes EJ" No ❑ FHA/VA: Yes ❑ No [�t— TYPE OF INSTALLATION AND SPECIFICATIONS: " I [No septic tank'or cesspool permitted if public sewer is available within 200 feet.) /Ji F Septic Tank: Distance from nearest well---------------- Distance from foundatioq �_____pu; _.Material__��___W_ . artments___ _y._ [ No. of com ! p - Size_�3&_'�l� uid de fih_ * ---------- . Capacity---� Disposal Field: Distance from near wel __________ ______Distance from foundation_____:___ ___ _.Distance to nearest lot line_%__________ Number of lines----- _,= Length of each line_ _�?`7-/ `_: Width .of trench_____��_`______________ ' _:-w --- l of filttr material- Q_G_ .____.___Qepth of filter materia- / -- Tota! length'- 71_------` ---------- Type Seepage Pit: Distance;fol nearest welt____ _._______Distance from 'foundation________.-- Distance to nearest lot line_______ . [ Number of pits__ _._________Lining materiae __ _____:__.Size: Diameter__ _.._.__Depth____...__._._______ ^' Cesspool: Distance from nearest well-----------------Distance from foundation------------------- materia- ❑ Size: Diamefer- ------------------------------------Depth------------------- --- •-----=-•----------Liquid Capacity----------------------------gals. 5 Privy: Distance Lrdm____earrest well-------------------------------------------------Distance from nearest building-'----.------------------------------- ❑ Distance to'nearest lot line....------------------ ----------------------------------------------- ------------•--- ----------------------------------- - ---------------- Remodeling and/or repairing[describe:------- ------------ ------------------------------------------------ ------------------------ ------------------------------------------------ _ . -;/ G 1 4 ______________ ,t } _--------________________________ e_______ _______________________________________________________________________________________________________________________________________________________________ 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 I s,' and rule and eguI tions of the San Joaquin Local Health District. r I [Signed} " ------- _.------- -------- ----------------------- By:------------- ---------------- (Owner and/or Contractor) gY' } - - ------------------------ --------- ----- --- - ----- --------- (Title) i (Plot plan,showing size of lot, location of system in relation to wells, buildings, etc., can be placed an_reverse side). ' ,, FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____ �- -- - �5`�'�?�-�� -- --.----- ------------------------ DATE---- - REVIEWEDBY--------------------------------------------- -------------------- ----------- -------------- - ----•------------------- DATE----- --------------------------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-I------------------------------------------------------ --` rAlterations and/or recommendations------------------------------- ---------------------------------------------------=-----,--------==---------------------------------------------------------- -•----------------------------------------------------------------•---------------------------------- --------------------------------------------------'--=-----•-----------------=-------- -------------------------------- ---------------------------------I --------------- -------- -------------- - i --------------------------------------------------------------------------------------------------- -------------------------- ------- -•--__ ------------- - ------------- -------------------------- 1 - FINAL INSPECTION BY:----- i lR - �� .------- ----- Date--------- �- SAN'JOA UIN LOCAL HEALTH DISTRICT' ? 1801 E.Hazelton Ave. 300 Went Oak Street 124 Sycamore Street 205 West 9th Street ' Stockton,California Lodi,Cdlifornia Moriteco,California Tracy,California