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APPLICATION FOR SAMTATION PERMIT 4 1 l (Complete in Duplicate) 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. 55449. JOB ADDRESS AND LOCATION ------------------------------------------------------------------------ -------- Owner's - -- Owner's Name------------------------------------------------ 15&e1_------------------------ -------------------- Phone-5-'_ EAddress-------------- ----------------------------- ------ 1�---- . /l,V�---------------------------------------------------------------------------------------------- Contractor's Name-------------------------------------- P"J:a f-S ;1W_-_', -—------------------------ Phone $7470 ----------- Installation will serve: Residence A Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Z Number of bedrooms JP' Number of baths I6 Lot ------------------------- Water Supply: Public system J0 Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ 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--------------------Material----_---____---------_-_-------_--__-_-___--__--. ❑ No. of compartments--------------------------Capacity-----------------------Size--------------------------------Liquid depth------------------------- Cesspool: ------ -Cesspool- Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- ElSize: Diameter--------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well--------------------------- -----------------Distance from nearest building----------------------------.----..-_----. ❑ Distance to nearest lot line------------------------------------------------ Seepage �V.f...--.Distance to nearest lot line-_�f______ Seepage Pit: Distance to nearest well____ p�(Q_ Distance from foundation__ Xr Number of pits_-__-/-------------Lining material_�b/j-----Size: Diameter_gX3_'*___ Depth Disposal Field: Distance from nearest well _-_-_.Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type _- .-------------__Type of filter material-_______________________Depth of filter material----------------------- Remodeling �r Remodeling and/or repairing (describe]:_ �,�,��•�at --- ------ -=-------5`f----------------------------------- -------- ----- . --------------------------------------------------------------------- it --- -------------------------------------------------------=---------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ hereby certify that,l h ve prepare applicatio that the work will be done in accordance with San Joaquin County ordinances, State laws, Ynd ules and r i ns o e San Joaquin Local Health District. (Signed)----Ll.l__6 � F3 ,-------------------------------------------------- -------- Contractor) By:------- ; {Title) ; (Plot plans, owi six o , ocation of syst in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- ------ - --- ---- -- --------- y --------------------------- DATE--------- -- ----------- - -- REVIEWED BY--------------------------------------------- - - -- --- ------ --- ----------------------- DATE----- � �' ------------- BUILDINGPERMIT ISSUED----------------- ---- ----- ------- --- --------------- DATE------------------------------------------------------------ Alterations and/or recommendations------------------------------------ ------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------I----------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------Y----------------------------------- ---------- -- ------- --------------- -------------- - - ---------------------------------- / r � p qq .. PERMIT Nol_. _ _Y ISSUED----------- ---2'C_ __,�- ----(Date FINAL INSPECTION BY:------------------ _------ Date---------------- '�,P '� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639