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APPLICATION FOR SAN! h � TATION PERMIT Permit No. _--:_-:•- =_ =� (Complete in Duplicate) i r _ i. --'Date Issued Application is hereba to the San Jo quin Local Health District for a permit to construct and install the work herein described This application is ma a in compliance with County Ordinance,No. 549. JOB ADDRESS AND LOC ON ' ' - ; } Owner's Name----- - ''' '----- L f $ . et-� --- Address..__!g Pho �rm�.__w•-•---- ------- ,I^K.o---- /t►0- v id. ie Contractor's Name __ gyp... --------------- Phone---..__ — [? Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: � Number of bedrooms _ Number of baths __d-_ Lot size --------.--/-- Wafer Supply: Public system ❑ Communitys sfem Y ❑ Private f!�, Depth to Wafter Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ Nodig, New Construction: Yes'EQNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank ar cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: Distance from nearest well _ _ -_pistance from foundation____ ,�^_ 01 +r e��er '�s __----.Material- ---- No. of compartments----r]/ ��C"�---�-i-�"�-�`,,,.----. Size_ _ x --- --_ Liquid depth----_S F Disposal Field: Distance from nearest well_ _ Distance fir foundation_ A oZ `-,..Capacity- Disposal asG_r '_.__Dhfance tolnearest lot lin e-__.____ Number.of lines-------- --__Len Length of each line____ N �1 g 4a Wid#h of trench----a Type of filter material _ Depth of filter material__-_._1�_--- Total length______�i !_-_ _ Seepage Pit: Distance to nearest well_______---------------Distance from foundation__ . ----_-__--.-_.Distance to nearest lot line__----_-_____-__ ❑ Number of pits----------------------Lining materia)________------------ ------------ Diame#e--'--_ ------. -----Depth------------------------ Cesspool: Distance from nearest well-----------------Distance from foundation___---------__-.Lining material__________________----_-_ ❑ Size: Mamefer-------------------------------------- , -----------------• -- � ------Liquid Capacity a1s:` Depth ------------g Privy: Distance from nearest vrell �___ __-________---.____.__--Dist nc from nearest buildin ❑ Distance to nearest lot line------------------------- ---------------------- 9 Remodeling and/or repairing (describe): �_ tGc�� xr ------------------ ------- ------- ------------- ---------_______________.._______-__- ___ ---------- •__-____-1-•-_- - •_-____ - -__ - __-K_ ___ _-•____________-__ ------------------------------------ ------------------ . _ _ _ _ ___________ f hereby certify t a I ave prepared this application and that the work will b done in acco dance with San Joaquin County ordinances, State laws, rules an :regul tions of Ae San Joaquin Local Health ss r°ict. (Signed) ' ------------- --------------- ------- --- --- By-------------•------- - -( r Contract -------- •- -----------(Title}- _ 0 or of plan, showing size of lot, location of system in ion to wells, build' gs, etc., can be placed on r arse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------,- REVIEWED BY _---______________ -------------- ---------------------------------------- DATE - BUILDING PERMIT ISSUED_ ------- DATE 7- `- ------ DATE------ ------------------- Alterations and/or recommendations____________________ ---------- ---- FINAL INSPECTION BY--------- ----- Date--------- -- •--•---t----- �----------- -� -- SAN JOAQUIN LOCAL HEALTH DISTRICT ' 130 South American Sfreef 300 Wesf Oak Sfreet 132 Sycamore Street 814-iLth "Z" Streef Sfock+on, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100