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Y FOR OFFICE USE: --------------- ------- ------ ------------ ------------- %4 APPLICATION FOR SAMTATiON PERMIT Permit No. -- -------------- ---------------------------------- --- (Complete in Duplicate) Date Issued ___ ____________________ This Permit Expires 1 Year From 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. JOSADDRESS AND C TION---- -- -------L--'� -`�- ------- -- ------- ----- -------------•-------------------- -------------g---•--•------ ---------- Owner's Name ---------------------------- ------- Phone_./._-3/•"-Q-�S-- _. lr� ` e Address - ..................... ----- -- ��// Contractor's Name �Ioo - ---------------- -------•-------- Phone-7...V_-..- � Installation will serve: Residence[Q Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ Number of bedrooms _e� Number of aths ---C._ Lot size ___/.-- .Z-------•------ j Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -'Vlpft. Character of soil to a depth of 3 feet:- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �ardpan C3a Previous Application Made: (If yes,date.#_ -_ �- _,_.___l No El New Construction: Yes ❑ No �HA/VA: Yes ❑ No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 't' Tan Distance from nearest weU_________________Distance from foundation--------------------Material-------..__._'_-________.._____------..______._. No. of compartments--------------- --- -----S••sze------- .------------------- -Liquid depth---------------- --------.Capacity-:--------------------- Id: Distance from nearest well 4P-------Distance from foundation_ .."---_Distanc'e to nearest lot line-- Number of Tines_____ _____________ ._-Length of each line___ ----e�____.Width of trench____-, _-_____` Type of filtei..Taterial_�� l�Ck-Depth;of filter material____ _�i__ f.Total length-------- _ _�___ Seepage Distance to nearest well_190---------Distant m f9undation___7it�___--- Distancs� to nearest lot line__ --S__..._ / _ f Number of pits._...___.__ -Lining material_ '_.!3_ -.�__.$ize: Diameter_._'_ - -.-_._- Depth__.. _ ________..___ Cesspool-, A Distance from. nearest well-_____ -------Distance from foundation___________________ Lining material___..----------------------._------ El __ __❑ Size: Diameter--------------------- - -------------De,pth------------------------------------------- --------Liquid Capacity_.---------- -------------gals. A Privy: " . Distance from nearest well---------------------------------:----------------Distance from near ---------l. ----------------- ❑ 4 Distance to riear13st lot line------ ------------------ ---- ------------------------------- ------- ----------------------------------- Remodeling and/or repairing (describe):------- ------------ ------------ --------------------- v----------------------------------------------------------------------------------------- � . - k ---------- ----------•-••-------------------- . + _ = #jv r I hereby certifyifhat I have prepay d this application and that the work will be done in accordant 'with San Joaquin County ordinances, S e- ws, s and r gplations f the Sa oaquin Local He th Di ric+. {Signed) -- --- ------ ------ -- --------- 0-w ------- = = ner and/or Contractor) }� By:-------------- ----------------------- ----------------------------------- (Title) - j (PIo+ plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on rever side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-.t---- DATE.---- f ------ ----- REVIEWED BY---------------------------- ----- • DATE-------- --------------------------------------------------- . -- -- ----- - -- ----------------- 7 BUILDINGPERMIT ISSUED--,-"------.--- ------------------- -------------------------------------------------------I---------- DATE--------`----------------------- ----------------- ----- Alterations and/or recommendations:----- ------- �� - ��`y`-� '-�=�`-= 2 ` E --------------------------------------------------- ----- ----------------------------------------------------------------------------------------------------------------------- i ---------------- ---------------------- ------------------------- --------------------------------------------------------------------- --------------- ------ -------------------------------------------------------- / FINAL INSPECTION BY:..<_ ...... rNJOAQUIN ` Date . LOCAL HEALTH DISTRICT1601 E.Maaelton Ave. 30k Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.