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APPLICATION FOR -SAVNVATION PERMIT Permit No. .__.� b.._ (Complefe in Duplicate) y Date Issued ---.1�. - 1 Applicaion+ is hereby made to the SanJoaquin Juin Local Health District for a permit to construct and install the work herein described. q This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LO TI Owners Name----------i � ' `" - ------ ----------------- ------ DSI✓ wl l.0 �/-- --------------------- i �—r - ------ Phone------------------------------------ ----- Address--------------- 3/ C`--- ---------•----------- -------••---------------------• -----------------------•------------------------- Contractor's Name------------------ -------------------------------------------- Phone----------------------------------- Installation will serve: Residence (a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms __2__ Number of baths I___ Lot size -------------- 34-----------------•- i Water Supply: Public system [I Community system ❑ Private K Depth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam El Clay El Adobe[T Hardpan E]P Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well__ ."? _.___Distance from foundation----��------.__Materi I_________________________._.__ Liquid de th--------- .----------Ca acit -- Q_ Septic Tank: No. of compartments_....... --------------Size--- x- q p. p Y Disposal Field: Distance from nearest well_."_��_�_....-Distance from foundation___/0--- -..-.Distance to nearest lot line__-.__ r_ Number of`lines____________-_ ---------Length of each line--------d-------.------Width of trench-------- -�r----.-.--.-.- _Depth of filter material_.--.-'0^__._.--Total length_________________/_?d_ _._Type of filter material_ _ ________Distance from foundation____.________._.___.Distance to nearest lot line----------------- Seepage Pit: Distance .to nearest well_____________ ❑ Number of pits---------i------------Lining material--•--------------------Size: Diameter-----------------------Depth.------------------------------- Cesspool: Distance from nearest well--------_--------Distance from foundation.----.--------------Lining material-----------------------------------__ El Size: Diameter------------------------------------- Depth------------------------- ---------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------------.--:------------------------.Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line---------- ---------- ------------------------------------------------------------------------------------------ -------------------- Remodelingand/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 re ulations of the San Joaquin Local Health District. - (Signe( �j'{ ',�"�a'- ----- �-- ------------------------------------------------------------ {Owner and/or Contractor} V ____(Title]____ ' B :__.... - --- -- ---- ------ (Plot 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 8Y----.--------- - -- ---- --- -------------- ----------------------------------------- DATE---------- REVIEWEDBY------- ------ -- ------------------------- ------ -------------------------------- DATE----- --- f BUILDINGPERMIT ISSUED------------------- ------------------:----------- ---------------------------------------------- DATE-------------------------------------------- ------------- Alterations and/or recommendations---------------- ------------------- -------------------------------------------------------._..---•---------------.._._.----------------------------------- ---------------- ---------------------- ------------------------------•-------------- ---------------------------- -------- - -------------------- 1 � FINAL INSPECTION BY__________ _ ___ __ _______ __________ --------•-•----- Date I --------------------------- 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 E5-9-2M 145446 ATWU" 52-54