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APPLICATION FOhSAN1TAT10N PERMIT Permit No. �y t li (Complete in Duplicate) pate Issued __��7�-��-- d +� This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health DistLrict for a permit to construct and install the work herein described. This application is made in compliance with County Ordi fince o. 549. JOB ADDRESS A OC ION y� --- ----------- ! - - Owner's Name--- - ---£ —'--G'=----------- --- Phone. AF:: ------- } Address.--2/ ------- --------- = --------- --- -- ----- --------------- - --------------------------- Contractor's ame---------- —--- C- �`rl r s 'z"--•------•--- Phone . _--_� • - Installation will serve: Residence Apartm . t House ❑ Commercial ❑ Trailer Court ❑ Motel Other [I Number of living units: ---/--- Number of bedrooms __ - ._ Number of baths _/__ Lo size ;W 0-/ T Water Supply: Public system Community system El Private E] Depth Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado1A Hardpan ❑ I Previous Application Made: Yes ❑ NOA New Construction: YesX' No ❑ PHA/VA: Yes ❑ N0-A" TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 20 Septic Tank: Distance from nearest well -Distance/fro fo}�idation�e-_le ------_-mat- ------ __ { No. of compartments-_ .2-----------------Size_��.._-- __-- ---------:---Liquidd depth_.)-- ---�------Capacity._.�dQ__----- Disposal Field: Distance from nearest wellDistance from foundatio /fes Distance to nearest lot I ne___ 1�___._.. i r---------- Number of lines---------f______...._._ ----- of each line--- ._ _�.�_i._-...Width of trench.__E ___�-_ --Total len th----_ --------------- Type of filter material -. _ _----_Depth of filter material--- g ------------------ Seepage Pit: Distance to nearest well__------Distance from f dation__/ ___-..___.Distance to nearest lot line.... /- O { Number of pits------ material, Size: Diameter__, _�-`_...___Depth_..•2 - ! / W Cesspool: Distance from nearest well_'____- -_.__-Distance from foundation..-.__-------------Lining material__.__ ____.._____.-________s F-1 Size: Diameter--------------------------------------Depth-------------------------------------------- ------Liquid Capacity----------------------------gal . Privy: Distance from nearest well ___._--------------------------------------------Distance from nearest building-.-.-._.___---._---_-.------__.-------.._. ❑ Distance to nearest lot line----------------------------- ------------- ------------------------------- Re�41eling and/or repairing (describe):___ -- - - --- --- ------ --- ---' ----- ---------------•---------------- -------- ---------.------ --------------------------------------------- ------------------ ------------------------------------------------- ------ ---------------------- ---------------- - - -------------------------•---• --------------------- ---------------------------------------•--------- ------------------------------------------------------ --- ---------------------------------- --------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this applicatio and that the work will be done in accordance with San Joaquin County ordinances, State laws, and r le nd reg lation of th an Joaquin Local Health District. (Signed)_ ----- '- - --------------------------------------------------------------(Owner d Contractor) ------- ---------------------------------------------(Title) 1 (Plot plan, ' e of lot, ioc of system in relation to wells, buildings, etc., can be pla don reve se sid. FOR DEPARTMENT USE ONLY ------- DATE-------- ----------------- APPLICATION ACCEPTED 13Y_ ---- ---- --- ------------------ --- ---�-- tom'""------------ REVIEWEDBY-----------------=---------- ---------- DATE----------- ------ ---------------------------------------- BUILDING PERMIT ISSUED----------------------------- - - --------------------------------- DATE----------------------------------------------------------- -- -- -------------------------- Altera ons nd/or recamm ations-------------------------------- -------------- - ------------ -------•----- --------------------------------------------------------------------------- ------------- --- ------ --------------- ------------------ ---------------------------------------------------- ------------------------------------------------------------- .._- _ -- - ----------------- __ ___________________________________________ ___________________________ _ __...--____-••-----------------------------------------•------_•---Iit-FINAL --- ...--------------------•_-------------- Date- 4INSPECTION BY---------------__.___.. -- - " SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 8-'S9,F.P.Co.