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[[ ,� Permit No. . -------- (Complete - -- APPLICATION FOR SA ITATION PERMIT,-, , - -- - - - C Com lete in Duplicate) f tj/A [ p _-Date Issued - -_ ___/_._: al Application is hereby made to the San Joaqui nyLocal,,Health District for a permit to construct and install" e work%e'rein described. This application is made in compliance with Counfy.. dinance No. JOB ADDRESS AND LOC tON ------ ------- ---- ,,yy Phone.---- '------------------------- Address ; Owner's Name--------- =1. '' ----------------------- ------------------ I r �� - •------------ Address----- _,416 '--------- } -------------------------- -- 1 Contractor's Name i1 ---- Phone- - :`= 4 - -----'- - ---- - Y �, -- Installation will serve: Residence �Apertment House ❑ Commercial ❑ Trailer Court- E]-_Mofel-0.;Other ❑` p� c t U Number of living units: _s Z_ Number of bedrooms -`"-- Numbl r of baths __ Lqt size ------ I e Water Supply: Public system Community system ❑ Private © Depth to Water Table -ye ft. 4 Character of soil to a depth of 3 feet: Sand Of"•Gravei❑ Sandy Loam ❑ Clay Loam ❑ Clay E] - Adobe��ardpan ❑ Previous Application Made: Yes ❑ No j?'I Ne%AGonstruction: Yes ❑ No ®G FHA/VA: Yes o 0 i' f TYPE OF INSTALLATION AND SPE1IFICA710NS:-- ' A `°' 1 (No septic tank or'cesspool permitted if public sewer is available within 200 feet. .f,r,. Septic Tank: Distance from nearesr��welL_-___-_______-_IQistance fro foundation__________ _______Materi i____-__------- -_---i�-_---.--______. No. of compartments-_----- ---------- Size._- - fro j---founds--Liquid depth--_•------.-------�-'--.--CapacityL-_-'!----------�--- Disposal Field: Distance from nearest well---_ -----Distance ---------Distance,•to�nearegt lot line-AP-__-_-_. �r Number of lines------------ _ --------__-------4Length of each line-____ ' � -----.-.Width of french--;- __ !-____�_______ Type ot"fi tier mate'ria] 'Depth of filter material____ «-_-_._Total length-------- -_-4V----.___-____ _r Seepage Pit: Distance to nearest well---------------------Distance fro foundation___-.-_ :._ __y-_:Disttmce to••near st lot line----------------- + 171 Number of pits----------------------Lining material---------- ---- -_---Size: Diameter------------------------Depth----- -------- -------:-------_-:- .y Cesspool: Distance from nearest well-----------------Distance fro foundation--------------.____.Lining material______------_-__ [] Size: Diameter------------------------- ------Depth_---------- ------------------=---------------------Liquid Capacify----------------------------gals. Privy: Distance from nearest well--------- ---------Distance from nearest-building---------------------------------- ------ ❑ Distance #o nearest lot line__-------. -------------------- --------------------- - ` ------------ --------- ------------------- ` _ _ i ` Remodeling and/or repairing (describe):----_. -----w 1 ----------------------------------- ------- , �. 1 �!�" r------- [ = ----------------------------- . ` --------------------------------------------------------------- --------------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance""ith San Joaquin County ordinances, State ws, and rules and r gulati s f the Sdn Joaquin' Local Health District. w • E [Signed} T " - = --------- - = --------------- -[Owner and/or Contractor) [Title - =------ ------ -•---•----------- ------------------------ ----------------- --.------ ----------------- :i ------------- --------------- ----- pian", k (Plot pia , showing size of lot, location of system in.relatiom -- to wells, I buildings, p s, etc., can be lacefl'on revers side). FOR DEP'_RTMNTP. SE ONLY APPLICAT C-�EP��D � - --------------------- -/DATE � 1 � ------------- ---- R EV I EW E ------------------------- DATE ---._--- - -------------------- y -. .----- ----= __ .� BUILDING PE MIT' SUED--=------ - - ----- - -------------------------• DATE--------------------------===---=--------------------------- r .. w,,... ,.r " Alterations ,att'd/a a mendat�ons-----------------=-------------------- ------- -------------------------------- - i'�- -- ••-•---------------------- ---- •----r----- " ,r -- '-'---------------- -----------------'--'- --------� ------------ �, -------------------- -------------.-___.------ ------------'------------------ -------- ----._ 1 i f FINAL INSPECTION BY----------------- - ---- - ------------------ -- Date------------------ ------ --------------------------------------- _ ..r SAN JOAQUIN LOCAL HEALTH DISTRICTS 130 South American Street 300 West Oak Street; � 132`Sycamore St erg O 814 North "C" Street = ' ( Stock+on, California Lodi,'California Manteca, California F Tracy, California i E$---9-2M , Revised 1-57 F.P.CO.