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l ' �ft ap APPLICATOPer it No 7.7': _7 �/ (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. JOBADDRESS AND L CATION------ ---------------------------- ------------------------------------------------------------------------------------------------- Owner's Name--------------- f --------- ------------- Phone-------------------- Address. .l = / = -- --------------- �4Contractor's Name-------- ,D_.`- _ ___ if ---- - ------ ------------- ------ Phone___-{,_G - -_ Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _I____ Number of bedrooms _. - Number of aths _J_ Lot size ---- r _ __/- �_j------------------ Water Supply: Public system ❑ Community system ❑ -Private Depth to Water Table ft. y Character of soil to a depth of 3 feet: SandGravel E] Sandy Lolay Loam ❑ Clay E] .Adobe €A' Hardpan ❑ Previous Application Made: Yes ❑ Na New Construction: Yes ;�No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) _ Septic Tan Distance from nearest well__='-Distance f om foundation_: Q_-__,_ Mate is_ ' ___________________P________, No. of compartments___-v _____-----------Size--- _ ----Liquid depth__��------Capacity_,�Ve-------- Disposal ______ u Dis osal F' ld: Distance from neare ,. well-_ _-Distance from foundat�i�ofnn �Z l________-Distance to nearest 1 f�ineJ�________- p Number of iines_--- _F______ Length of each line__-_�--�- __.Width of trench__ _{ Type of filter material- OC --Depth of Ater material__ ________Total length____ � ______________ Seepage Pit': Distance to nearest well--------------------_Distance from foundation----------------.__.Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- x Cesspool: Distance from nearest well----_------------Distance from foundation--------------------Lining material___________________z._______________. ❑ Size: Diameter--------------------------------------Depth------:---------------------------------------------Liquid Capacity----------------- , -- gals. : . ..� Privy:. Distance from nearest well ____ ________ - ____-'______ _ _ ___Distance from nearest building------------------------------------------ El ____.-____________ ______ ___ _______- ❑ Distance to nearest lot line------------------------------ ---------------------------------- ---- --------------------.---------------•---------------------------- Remodeling and/or repairing (describe)=:-----------,;/- `----- -------------------------------------------------------------- --------------•------•-•----------------- --------------------------------Z_-------------------------------------------------------------------------------------------------------------------------------------- 1 -------------------------------------------------------------------------------------e---------------------------------------------------------------------------------------------------------------------•---------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, a d rules and regulations of the San Joaquin Loc. Health District. 1 Cj -- (O er and/ _Contractor) " (Signed) - - ----- ------ --------------- -- -- -"{---e---3 - --- - ----'---------------------------------------------------- (Title- -- --- -- { SY ) - -- 44 (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 r C r,--;sr--- - "� / ,- REVIEWED BY - -`-------------------------------------------------•------------------------ DATE - -------- ----------- BUILDING --- -- --- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:----:----------------------•------------------ ----------------------------------------------------------------------- ------------ i ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY-------------------1/--------------�ftr--=-.-f-�---- Date----------------------------------- 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 8-51 Revised W-2100