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rvx VrrlC.t USt: -G---------------------- `'r --------------------------------------------------------- APPLICATION FOI"-SANTTATION PERMIT Permit No. . -------------- ----------- -- ----------- ---_------ (Complete in Duplicate) ----------------------------- ------------ - ----------- This Permit Expires 1 Year From Date Issued Date Issued 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 No. 549, JOB ADDRESS AND LOCATION_..--- ----------------------------- Owner's Name---___--- _--------- Phone _-73�v-f-- --------- --------------------- -- - ---- --- ----- ------------ Address-----•-•-/--.2 2 - - Contractor's Name________________________•__-_______• __ - ----- -- ------------- --------------- - --- ------------ Phone................. - ----------- - ••- - - •- - Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [3 Number of living units: _- Number of bedrooms jw'5—_ Number of baths _/__ Lot size ----0- ___- _�', _-- Water Supply: Public system E] Community system E] Private El Depth to Water Table �®ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobet Hardpan ❑ Previous Application Made: (If yes,date--------------------) No New Construction: Yes, ' No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if.public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--- Distance from foundation_��----------- Mater al.____ f - I No. of compartments-------; -- -------------Size__JX_7k��7---Liquid depth------- ---.--------_Capacity__ �Q_ ,44 Disposal Field: Distance from nearest f Di wefi.__ Q_�_ stance from foundation._ __ q � -_----_-____Distance to nearest lot line--- Number of lines.-_.____aS-------------- ------ - Length of each line------ .--- -___-------Width of trench------ --------. __ Type of filter material___ _ Depth of filter material----.lj _��__Total length----------1__W_ _ ---__--------•- Seepage Pit: Distance to nearest well___ fGG__---_Distance fra'' foundation----l0_--___-.Distance to nearest lot line___t�_�___. J Number of pits_____ _____________Lining materia l_____Ajlt�e ___Size: Diameter----%-;Z7��----- Dept h------tP52.j$'r \t ----------- Cesspool- Distance from nearest well----------------- from foundation--- ----------------Lining material--..-.------------- El Size: Diameter------ --------------- ---------------Depth-------------------------------------- -------------Liquid Capacity----------------- ----------gals. Privy: Distance from nearest well--------------- ---------------------------------Distance from nearest building '% ❑ Distance to nearest lot lin e---------_--------------------- Remodeling 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 regulations of the San Joaquin Local Health District. (Signed-•-------------------------------- ----- ------ ---------(Owner and/or Contractor) BY:------ . ----------------- --------------t=-6 V7 --�- - Title--------------------------- --------- --- Plot fan, shover � -- - -tr3---- ----------{ ) ------ �- - ( p g size of lot location of system in relation to wells, buildings, etc., can be placed on reverse side). OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- - -- - ------------ DATE------�' --�i ------------------------------ REVIEWED BY ---- ------------ - ------•--- DATE BUILDING PERMIT ISSUED---------- ------ DATE---------- Alterations and/or recommendations___________________ i '.-------°1.6--------- FINAL INSPECTION BY:----------- - Date---.----�1�-�4- ,+ - -- - ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.