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APPLICATION FOR SAF41TATION PERMIT Permit No. . ....... . <br />(Complete in Duplicate) <br />Date Iss ued,:R __14/ <br />Applical-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br />This application is made in compliance with County Orinance No, 549. <br />JOB ADDRESS AND LOCATION]-- Ad- <br />---------- ------- --------------------- - --- - ----- - 0_4�_Ov ----------------------------- ----------------------------- ----------------------- <br />Owner's Name ---- <br />--------- --------------- - ----- --- - -- ----------------------- ---------------------------------------- -- Phone__6 Z f,,7 <br />Address---------------------- ---- --- 0 <br />------- ----------- - -- --------------- ----------------------------------------------------------------------- <br />- <br />Contractor's Name -- --------- <br />- ------ - ----- ------- - -- --- --------------- --- -----------------­---- --------------------------------------- Phone-- <br />�/9�� <br />Installation <br />hone--Installation will serve: Residence E] Apartmgnf House E] Commercial [] Trailer Court [] Motel 0 Other 211 <br />Number of living units: 1__ Number of bedrooms ---%_.. Number of baths ---/--- Lot size <br />Water Supply: Public system E] Community system E]Private 5R/Depth to Water Table <br />I <br />Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam F'�a rd n <br />Clay Loam E] Clay E] Adobe 9j--_H pa j <br />'T:A-7." <br />Previous Application Made: Yes E] i No Eg-`New Construction: Yes �No E] <br />TYPE OF INSTALLATION AND SPECIFICATIONS: <br />(No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br />Septic Tank: Distance from nearest well ..... 070 ------ Dista c,,Jrom foun�afion ------ Material --- <br />No. of compartments..------/--------------Size- -Li,.id depth----x.16.----------Capacity--h-p_'' - <br />I r <br />Disposal Pie tante from nearest. well__ ........ ... Distance from foundation --------- 0 ---------- Distance to nearest lot line ----------------- <br />umber of lines-11 - ----------------- �_ -Length of each line------------------ ------------ Width of trench <br />I ;� ; ------------ --- <br />Type of filter material ------- ------------ ; --- Depth, of filter material ----------------------- Total- length -------------------- ------ <br />II I -- -------------- <br />Seepage Pit: Distance to nearest wel� ------- 44 -------- Distancd fro oun a�ion ------ 0_C/_`___.Disfance to nearest lot line ---- <br />Nur�ber of pits.4-J --------- Lin a ------------ A Diameter ------- `3 -3 Depth ---- C?�_S <br />t - - - -.Size: <br />Cesspool: Distance from nearest —well-----____-.__ Distance from ' foundation------------- ----- Lining material_--.--__.-------___-------___----.--_. <br />F1 s Size. Mameter ...... ----------------------------- Depth------------I ------------------ <br />Ir ------ -------------- Liquid Capacity--, ------------- / - --------- gals. <br />Privy: f Distance from nearest well -------------- --------- ------------- Dstance from nearest building -------------- 40 ----------- ------ --- <br />Distance to nearest lot line -------- Z _42e <br />Rem eling and/or epa',ring fclescrJ, 'Ill 777 -- ----- I 1_ <br />----------------- <br />- - ---------------- <br />----------------------------------------------------------------------- -------- ------ ­ --------------------------- <br />------------------------------------------------------------------ --------------------- : --------------------------------------------- ------------------------------- <br />---------------------- --------- -------------- <br />-------------------------------------------------------------------------------------------------------------- I ---------------------------- <br />---------- ---- * ----------------------------------------------------------------- <br />I hereby certify that 1, have prepared this application and that the work will -be done in accordance with San Joaquin County <br />ordinances, State laws and rules and regulations of the San Joaquin Local Health District. <br />- ----- -- ----- --- -- --- ---- <br />(Signed) ---------------- -------- t2nrt - -------------------------------------------- ! ---------------------------- 10" ie and/ol'ir Contractor) <br />By: ----------- ---------- --- I - --- -------------------------------------------------- -------------------------------------(Title)--- <br />----------------(Tifle)--- ------- -- ------ ------- - ---------------- <br />(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on -reverie side). <br />.4 FOR DEPARTMENT USE ONLY <br />APPLICATION ACCEPTED BY -------------- --------------------------- ------ Vf- -5 --------------------------------- - DATE------ <br />-------------------------------------------------- -------------------- <br />REVIEWED BY --------------------- ---;$ ---- 1( ----------------- <br />BUILDING PERMIT ISSUED ------------------------- -------------- DATE - <br />----------------------------------------------------------- <br />I --------------------------------------------------------------- DATE----------- <br />Alterations. and/or recommendations: ------------------------- --------------------------------- <br />- <br />-------------------------------- <br />--- ----------------------------------- ; ------------- -------------- --------------------------------------------------------------------------------- ------- ----------- --------------------- ----------------------------- <br />FINAL INSPECTION BY:._ --------- vh4 ----------------- Date ------------------------- — ----- Lt_7777!1�:_ <br />SAN JOAQUIN. LOCAL HEALTH DISTRICT <br />130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br />Stockton, California Lodi, California Manteca, California Tracy, California <br />ES -9-2M Revised W-2100 <br />