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APPL�C ISN FOR SAN[TAT) N PLRM t'Permit No. ____.! d_s" (Complete in Duplicate) 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 AND LOCATIO Owner's Name---------------••- � Q?�---•-- —-`:} - Phone----------------------.------------- Address . ,v ) - ` -------- . 1 ------------------------------------------- Contractor's Name---- ---....--------------------------------------------- ✓ Installation will serve: Residence ® Apartment House E] Commercial [-] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_ Number of bedrooms -_3-- Number of baths I____ Lot size ---.Qo_______-��'�°��l Water Supply: Publicisystem ❑ Community system ❑ Private [N Depth to Water Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E❑ Clay ❑ Adobe gs Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction:,Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public se er is available within 200 fee}.) Septic Tank: Distance from nearest weli__�&Y_Distance fro fou n ation___1�--______.Material_____-r�21 - No. of compartments __ a p Size-- ----._Liquid depth------- ---------Capacity--- Q L Disposal Field: Distance from nearest we11------ .......Distance from foundation_--- _'-fe/---..Distance to nearest lot Number of lines------- _�w--F___..___Length of•each line_�ay0� �Width of trench_______ f�----__---- �► Type of filter material_. - dt -___ Depth of filter material___. '*-.____Total length_______- £.�_�________________ Seepage Pit: Distance to nearest well ___------------------Distance from foundation--------------------Distance to nearest lot line__.__.____.______ "v ❑ Number of pits_-------,_-----------Lining material-----------------------Size: Diameter_----------------------Deptn- ------ Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material------------------------------------- ElSize: Diameter--------------------------------------Depth----------------------------------- ------Liquid_Capacity----------------------------gals. Privy: Distance from nearest well-------------------_-----------------------------Distance from nearest building_______._______._______________.------ ___ ❑ Distance fo nearest lot line - ------------------------------------------ - -•---------------------- Remodeling and/or repairing (describe):_.:.'QGL------ t � lf - ---- ,t ¢"!�'°-•----------------------- -----------------•------------------••---------------------------------•------•-------•----------------------------------------------•-••----•----------•-------------------------------------•------------------------------ ----------------------- ---------------------•----------------------------------•---------------------•--------------•--------------•--------------------•---•------------------------------------------------------------------------ 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)--------- pit'—l-rual-----0� / -- ------------- ----------- -------'-------------------------------------------------------------------{Owner and/or Contractors By:------------------1 -----------------(Title)--------------------- ------------------------------ (Plot plan: showing si+e of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FQR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ ------ ---------------------------•---------------- DATE----- ��--- REVIEWEDBY----------------------------------------- ---------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED-------------------------------------------------------------------------- --------------------------- DATE----------------------- Alterations and/or recommendations___________________ — ----- -•-------------------------------- -------- ------------- ---------•-------•--------------•----------------- ---- -------------------•------------------------ ---- ---- - --------------- -----------------------------------• ------- -- ------------ -----------------•-----------------------------------------...----••----------•---------------------------- ------------------------------------------------------- --------------------------------------------------------- FINAL INSPECTION $Y:. -----1------------------------•- --- Date-- -----___��_7J 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--•-2M 10-52 Revised W-2100