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APPLICATION FOR SAi ,.. ATION PERMIT Permit No. �j I (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to cons ruct and install the work herein described. This application is made in compliance with County Ordina No. 549 J08 ADDRESS A LOCATION --------------------------- Owner's Name- --------... Phone_ze_`!-eC� f------- ---------- Address ----/Z.9-40 - --- .-- , Contractor's Name_____________ Phone .. ____�___,��-27 Installation will serve: Residence Apartment use [I Commercial ElTrailer C urt E] Motel Other 0 Number of living units: 1 ----- Number of bedrooms_ Number of baths __/-__ Lot size ___.______________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdoW Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: YesX No ❑ FHA/VA: Yes ❑ N TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 4ecae Distance from nearest well_______________ Distance from foundation__________________.MaterialNo. of compartments--------------------------Size----------------------------=---Liquid depth ---------------- ---------Capacity---------------- �ti Distance from nearest well_________________ Distance from foundation____ -_________.__.Distance to nearest lot line________.___..__.g .Number of lines--------------------------------- Length of each line ------------------------------Width of french------- _-----------------------+V�Type of filter material -------------------------Depth of filter material --------_--------------Total length_ ----------------------------------------- Distance to nearest well Distance from f ndation ,Q�_____-Distance fo nearest lot hne_�_,~_ Number of 1ts.. __ g i_y'�7 _._Size: iameter�T'.-�///p �---------------- Linin materia - ----..Depth--.2..<—'- -- ---- - .a Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material _______________________.___-___-___. ❑ Size: Diameter------------------------- ------------Depth---------------------------------------------------Liquid Capacity ---------------------------- g4ls. �. Privy: Distance from nearest well ----------------------------------------------- ..Distance from nearest building ------------------------------------------ ElDistance to nearest lot line --------- --------------------------•---------------------------------------------------------------------- -•-------------------- Remodeling and/or repairing (describe):_____ _ _ _______ __ '____ r�.. -------------------------------------------•------------------------=-----•---------------------------------------------------------------------=--------------------------------------------------------------- -- --------------------------------------------------------------------------------------------------------------------------------•--------- -------------------------------------------------------------- 1 hereby certify that I have prep ed this applicati and at the work will be done in accordance with San Joaquin County ordinances, St to laws d rule an r elation f t an aquin Local Health District. (Signed)--- '----------- - �____.,_(Own and/or Contractor) By:----------------- (Title(Plot plan, showing size of at, 1 system in ion to wells, buildings, etc., can be rev se side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------ ---- ---------------------- -------------------------------------------- DATE--------- t , 1\, REVIEWEDBY -------------------------------------------- ---- - -- - - - - ----------------------------------------------------- DATE---- --- -'"----------------------------- BUILDING PERMIT ISSUED - - DATE Alterations a . d/or recommendations--------- -----------------------------------------------------------------------------------------•-------------•-••-------- ------------------------------ ----------------- ----------------- ----------- -- - ---------------------------------- - -------- /; Ai ---- -- R--------------- A_e FINAL INSPECTION BY:----------'� za.e a "` y' ' ---------------------Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M , Revises 1-57 F.i'.CO.