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APPI_ICA l" �FO SANIT-ATIkON—PE-RMIV Permit No. (Complete in Duplicate) Date Issuedl3__�S 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. 549. ` JOB ADDRESS AND LOCATION-- 0-_I4.__-11 R----- _ •-•------------------------------- -------------------------------- --------------- Owner's Name - 4 ' -------_- Phone--------------- �----------------------- Address------ - - ---Address------ --- Contractor' =-Contractor Name ------ ------- --.----••---- Phone-.Cs.-� Installation will serve: Residence partment'House ❑ Commercial ❑- Trailer,Court_[] Motel ❑ Other ❑ Number of living units: -a?-_ Number of bedrooms 3(- Number of baths -*q-- Lot size _ _le Water Supply: Public system [��Commun'it system 6 y y r ❑" Private ❑ Depth to'Water Table'��: ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobelardpan ❑ Previous Application Made: Yes P No ❑ New Construction; Yes Rq-17o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: 2 (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) No. of com ar#menu Size . + = ndation Material *-`------------ -------------------- El ------ eptic ,fin-, Distance from nearest well________________Distance from fou-------Liquid depth!_____________-_-______Capacity----------------------- Disposal -._______-_:___-...._ Dis o�s�field: Number of linesearest well."_..-:.Distance from founclation_f-------------�____-Distance to,nearest lot line-'10- - -:.Distance p from 'Length of each line_--9419-`4...... -- •----- � -- .-----Width of trench---- _T-l�---- Type ,of'filter material/- _ Depth of filter ma#erial--/0 ��___•__-Total length----_.I1�'- --='------------------•-- --- Seepage Pit: Distance to nearest wall_-_- ;.fir _=_Distance from four anon_._ ___.__..pistance to nearest lot line---1. O_ P g _ Size: _. Number of pits----/ Linin material __� �� X ------- ------------------Lining material----------------------------__- ❑ Size: Diameter. r -Depth ------------ ---- ----- - - , � '��,.� - -- Liquid Capacity--------- -------•-------..gals. Privy: Distance from nearest well---------- ----- ~-� ---.-:- Distance from nearest buildingb1 - ----... --- - ❑ Distance to nearest lot gine--..-_r_--'�4.---- ---------------------------------ate . w Remodeling and/or repairing (describe): - � ----------------- •--- ------ ---- ------•------------------------------ 1 ---------------- -------------------- ---------------------------- `:.�f - ------------------------------------------------------ -------•------------- ----------------------------- -----------------------!------------------------- ---------------------------- - - I bereby.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 regulations of the San Joaquin Local Health District. (Signed) dweer---- --------(O and/or Contractor) By:.__.. ---------•------------ = ¢ `- ' " = = - (Title)-------------------------------------- (Plot plan, showing size of lot, location}f system in.{relation'to wells; buildings, etc., can be placed on reverse side). FOR bEPARTMEIVT'USE ONLY APPLICATION ACCEPTED BY---.-------_`-___ f�--=---- - - -------------------`---------------------------- DATE..--------------- - - REVIEWED BY --- '-- --- •--------- DATE------- ---------------------- ' BUILDING PERMIT ISSUED--------------------- --- f --•--- DATE-----------rati - Alteons and/or recommends+ions----------- ------ -r� -._-- -_-__--:---- _-:---.___ `�c= f y --1 ----a ---------------------•------------ ------------•------- -------------------------------------- ---------------------------------------------------------------- ------------------- FINAL INSPECTIONBY: .- :. r•l �==- '= = ' Date-- --, -----�---------- - ' UUU SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South.American Street 300 West Oak Street 1 132 Sycamore Street 1 '. 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 6----9-2M : Revised 1.57 E ECO.