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_ r�x�ri(_t USt: 1:11) 4. 9 $.� -----------------/a lvc --. APPLICATION FOR SAMTATION PERMIT Permit No. _____.. -_-...._....... --- ---------------------------- ------- (Complete in Duplicate) _--- .-..._".--- This Permit Expires 1 Year From Date Issued 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 LOCATION___.__. -- ' Owner's Namet--------- ------------- Address------C1 --Address------C1 _ / - ' ------------------------------ Contractor's -------------------Contractor's Name---- ---- ---- ----------- Phone._7_ �� -•--------.•--------- Installation will serve: Residence E'partment House E] Commercial E] Trailer Court F1 Motel El Other 0 Number of living units, __ _'._ Number of bedrooms __s _ Number of baths _Z_- Lot size Water Supply: Public system [/Community system ❑ Private ❑ Depth to Water Table -S�� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ![Hardpan ❑ Previous Application Made: (If yes,date....................I No ❑ New Construction: Yes ❑ No U4- FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet.) tic nk: Distance from nearest well"________________Distance from foundation--------------------Material--------------_.___...__."-_"__._...--___.._--. No. of compartments--------------------------Size---------------•----------------Liquid depth.-------------------------Capacity Disposal Field: Distance from nearest wellZ-??°t-'�'_ ti Distance from foundaon-0_�_f--_ __ Distance to nearest lot line----------------- i �r Number of Lines______ _____ _ Length of each line..... ��' _ Width of trench--- y__._____._______._"-- Type of filter material_=' __ _ '.�__-Depth of filter mate rial___fse----------Total length------------------------------------------ Seepage _"-_.-._.____ _- G---------------Seepage Pit: Distance to nearest_well ' ---Distance- foundation_-- --------Distance to nearest lot line_-. _.__._.. `'/)j . ----f Depth- ---------- r +.5- Number of pits__..�_____.___..Lining materiaE_ _ am-��..___.Size: Diameter--3:.3 Cesspool: Distance from nearest well---------- ---_-Distance from foundation--------.:_.......-Lining material________________________..__.. ❑ Size: Diameter------------------ -- ---------------Depth------ --------------------------- -- -------------Liquid Capacity------------------ ---------gals. Privy: Distance from nearest well-----------.-------------------------------------Distance from nearest building_____...""-----__--_.__________._.__..._. ❑ Distance to nearest lot line.----- ----- Remodeling and/or repairing (describe)--------------------- ------------ -------------------------------------------------------- -----------------------•-•-••------- -----Z; ------=---------------------------- --------------------------------------- ---------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County -----------------------------------------------•------------------------------------ ----------------------------------------------------------------------------------------------------- ` I ordinances, Stat maws, d rules an re lations of the S n Joaquin Local Health District. (Signed)--------------- ------- --- ---- - -- a-_--- ( caner and/or Contractor) --- -- - ------ -------------------------- ----- Plot Ian, showing of lot, location of system in r- --- ----------"--"--"-"-.-(Title)_ -_ ..� _______________'_--"----.-.-_. ------- ------ ( p g y elation wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY t.._.� ------------------ DATE------b - ----------- ----------------------- -- REVIEWEDBY--------------------------------------------- -------------- ---------- -------------------------- --------------------------- DATE BUILDING PERMIT ISSUED------------------------ -------------------------------------------------------------- DATE Alterations and/or recommendations:-- ---- �'J��=--- ----------- ----------------------------------------------- ----------- ------------------------------------------------------------- ---- --- -------------------- ----------------- ------------------------------------------- ------------- --------------------------------------- ------------------------------------------------------------------------•---------------------------------- --------------------------------- FINAL INSPECTION BY:--- .---------- �Q_�f /------------- Date---------- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Avo. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy, California F.P.Q0.