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APPLICATION FOR SANT A TATION PERMIT Permit No.C->, (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. 544. j � /f JOB ADDRESS AND LOCATION hJ s`-c.c"-7�±�`_--,-€± - G .' .�- Owner's Name-------------------- .i ------ � --•---------------------------- -------- ---------------------------- Phone-------------------------=----•----- Address----------------------- z't°3-�r ------�~-�-d '` '= ----``-' '-------------------- Contractor's Name-------------------------------------------------------'-"-8.-6d-✓------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size --------------------------------------_---__---_----------- Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam.❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material-_-_----------_-____-_______----___-_______-_--. ❑ No. of compartments--------------------------Size-------------------------------Liquid depth---------------.-----------Capacity----------------------- Disposal Field: Distance from nearest well-------------_--.Distance from foundation--------------------Distance to nearest lot line--------.---._-_. ❑ Number of lines-----------------------------------Length of each line------------------- -------.Width of french----------------------------------- Type of filter material------------------------_Depth of filter material-----------------------Total length-----------_----__-_.--_-____-_-----.._ Seepage,Pit: Distance to nearest well--------------------_Distance from foundation--------------------Distance to nearest lot;line------_-----_--.-1� ❑ Number of pits--------- -----------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material.____---_-----------_---- V XSize: Diameter----- -------------------------- ----Depth----------------------------------------------------Liquid Capacity----------------------------gals.. 4 Privy.. Distance from nearest well-------------------------------------------------Distance from nearest building------_-------------_-_------_------___•-- t❑ Distance to nearest lot line-------------------------------- ------------------------------------------------------------------------------------------------------------ Remodeling ----- --------------Remodeling and/or repairing (describe)-------------- ---.-- _-•- _- ---._.._......-- ----------- `'a �` -------------------------------- P --------------I.........----------------_------•-•-•-------••_-_-----_••___.._._....-------------------------------- --------__--------_ ---JWf.--- -------- `"--_•--_ ___--- --------------------------------------------------------------------------------------------------------------------- ------------ -- ------ -_-_________.--__-------------------- --_ --- -- ------.-_.---_ 1 ----------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that 1 have prepared this application and that the work will be done in aycordance with San Joaquin County ordinances, State laws, and rules and 'regulations of the San Joaquin Local Health District. ... I -------------------------------Owner and/or Contractor By:----------------------------------------------- -----------------------------------------------------------------------------------(Title) f ---------------------------------------------------- (Plot plan, showing.size of lot, location,of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- ---------------------------------------------------- DATE-------------- s REVIEWED BY------------------------------------ ------- ----- -- -----=-------------- ------ ----- ------- --------------------- -- DATE---------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------=--------- --- -- ------------------ DATE------------------------------------------------------------ Alterations and/or recommendations--- ---------------------- -- -----------------------------------------------------------•--------------------------- - -------- - -------------------------------------------------------------------------------- --------- ----------------------------- ----------------------------------•----------------------------------------- FINALINSPECTION BY-----------------= ----------------------- --------------------- Date------------------------------- ------------------------------------- i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreef 300 West Oak Street 132 Sycamore Street 614 Norfh "C" Sheet Stockton, California Lodi, California Manteca, California Tracy, California r =T F� ES-4-2M 8-51 Revised W-2100 - �-