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`APPUCATIOW FOR-SAN I ATION PERMIT s (Complete in Duplicate} �. -Application is hereby made.,to-the San Joa`gamLocal Health Distract for a permit to construct and install the work herem:,described: yThis application is made in compliancwith County Ordinance No. 549. o,. --'. -------------------------------- -------------------------- JOB _ ADDRESS AND LOCATION___.---- app----- ' ---- _ G Phone-------------------------------------- , �K Owner s wName-----------------�.'-�-'----------- -- ---------------- --------- --- � 4 _ . _ -:Address---- Q - s.. - Phone-------------------------------- :f Contractors Name_------•-------------- ---------------------------------------------- -- A Installation wilt serve:-'Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel El Other ❑ t Numit ❑ `Number of bedrooms.❑,� Number of baths ❑ Lot size__ ___________(eA__�_I___d__ __- ber of.living uns L Water Supply: Public system ❑ YCommunify system ❑ Priyate J Character of soil to a depth 'of 3 feet: Sand ❑ Gravel ❑` 5andy .Loam El Clay Loam E] Clay El Adobe Hardpan'❑ TYPE.;OF INSTALLATION AND SPECIFICATIONS: - (No septic tank or cesspool permitted if public ewer is available within 204 feet.} Septic Tank: Distance from nearest welJ------0___Distance from - foundation------ Q______ aterial__________liquidf1depth_No. of compartments---------- 3------------Capacity ---------Size -r'--- -=__---- ces�ool: Distance from nearest well-----------------Distance from foundation____________-__.__-Lining material_____-_-____________--___________._ ❑ Size: Diameter---------------------------------------Depth---------------------------------------------------- ;Privy: --------------------- -- ----;Privy: Distance from nearest well------.------------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to,.nearest lot line------------------------------------------------___Distance from foundation--._______________ Distance.to neatest lot line__._______ __ 'Seepage Pit: Distance to nearest well___________________ .� ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-----------------------:-------` .._ ___�iata�ee #a Reatest-lotlin8--- --r "^ .Disposal'Field: --E)istance Number of lines----------------�)--------------Length of each line---- -@___!�_' -0------Width of trench---------Z`y____------------ } Type of filter material--,-1i__TVk___--Depth of filter mate rial__:___L'E___-____.__� dh �' Remodeling and/or repairing {describe: � _ _ ----------------------- - ------------------------------ -_ - ------------------------------------------------------ -I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, and ules and regulations of the San-Jo a uin Local Health District. / ------------------(Owner and/or Contractor] --------------------------------- (Signed)-------•-- - ----- --- t By--------------------- -----------------==-------------- (Title} — (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). i _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - 11f DATE--------- /S/--"0-------------------------- - ---._ ------ DATE ------------------- ' REVIEWEDBY------------------------------------------------ -- --------- ---------------- --------=------ - � -BUILDING PERMIT ISSUED--------------------- -- DATE------------------------------------------------ Alterations and/or recommendations:---•------ -- - -------'- - ---- -- - ---------••---------------------------- ___ ______ Y- fi _ ______________________________________________ f p ====__ --- - -- ---- ---�= ------- ---------•-- ---- _ --- -- ----- - ------------ PERMIT No----- ------- ISSUED------------------------------ (Date) FINAL INSPECTION BY: --------- - '------ ----- 'Date---------------------------l�� -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639 '