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TIQN PQR SANlTATlQ N PE `7 ., PERMIT Permit No. . :_�.---_-�_c ' (Complete in Duplicate) Date issued Application is here by fade t he $ uin Local Health District for a permit to construct and install the work here This application is made in compliance with County Ordinance No. 549. �n described. 11 M JOB ADDRESS AND LOCATION___.__ r- Owner's Name_----•----------- ' a - --- -------------------A----------------------------------------- - Address-------------•--------�-�- ^� ---------------- --- Phone_---•------------------------------ Contractor's Name---------•------�----=--- ---------------------------------------------------- Apartment •------------ Installation will serve: Residence Apartment House ❑ Commercial Phone_____-------------------- F . ❑-, Trailer Court f] Motel Number of living units: _� Number of bedrooms __�_ Number of baths ___`�__ Lot size ❑ Other ❑ Water Supply: Public system "3 ">- _ Pp Y' t Y ❑ Community system �] Private Depth to"'Water Table i Character of soil to a depth of 3 feet: Sand [I Gravel [] Sandy Loam ❑ Clay Loam Previous Application Made: Yes No ❑ Clay ❑ Adobeardpan ❑ ❑ New Construction; Yes [?r'No ❑ ,; .� TYPE OF INSTALLATION AND SPECIFICATIONS:.,` r (No septic tank or cesspool permittee! if public sewer is available within 200 fee+.) Septic Tank: Distance from nearest well-SrA-�_-___Disfa ce from foundation-___ 'd P a Material No. of compartments-----�.----------- / , ----------- ------- - '------Liquid depth_'"--................Capacity___ _ Disposal Field: Distance from nearest well___ ` _ Distance from foundation 0_+�'+ 0 � r Number of lines________-_ --_- , .- --Distance to nearest lot line--&P 4----- 4 - -----_--___ Length of each line __�_�-6_ - - --• f Width of trench Type of filter material-- - -- of fitter materiaL____�______ Total length----- --�_0____________ ________ Seepage Pit: Distance to nearest well------------------ ---Distance from foundation____________ ❑� Number of pits_____________________Lining material----------------------- Diameter-----!: -------Distance to nearest lot line____________-_-__ --------Size: Diameter- --r-- ------=-----Depth---------------------------- Cesspool: ' _ Distance from nearest well______________._ Distance from foundation _.___._________.Lining material L1 Size: Diameter._--- -------- --------Depth----------------------------------- ---------- Liquid Capacity-- -------------- Privy: � Distance from nearest well .........................gals•- _________.._Distance from nearesf building-_ �� ❑ Distance to nearest lot line---- ------- -------------- --- ----------------------------- ------ - ----------------------------------- --------------- emodeling and/or repairing (describe):------ --------------------------------------- ------------- ------------------------------- ---------------- ------------------------------' ------- ------ I hereby certify that I have prepared this application and that the work will be done in accordance-with San Joaquin County ordinances, State laws, and rules and regu ations of the San Joaquin Local Health District. (Signed) t ---------- By:------------------•--------------------------- = (Owner and/or Contractor) ----------------------------------•-----------------------------(Title)--------------------------- ------------------ --- -- (Plat 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 ___ __ Z .� ..,. REVIEWED BY _ ! ----------------- DATE BUILDING PERMIT ISSUED--------------- ---------------- DATE ----------- ------ ------------ .. r'--•----------------------- aerations and/or recommendations: = DATE ---------------- -------------- 1---------- ----- ----------------------------------------------- ----------------- •---•------------ ---•----=--- ------------------ - ---------------- ---------------- FINAL INSPECTION BY:----------___ - Dat---------------------- e------------ I� F�--" ,;------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Stir 04 30o West Oak Street Stockton, California . 300 Sycamore Street 814 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-2M 4 Revised W-2100