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APPLICATION FOR SAN1TATl®� NED Permit No ?j ✓ (Complete in Duplicate) 0, ,,,5'� _ L Date issued �_.__../�_____ DApplicafion 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 o. 549. e JOB ADDRESS AND L000 ------- - --- ---�---- - - --------------------- Owner's Name------------------ Phon Address------ r ----- -r ....... -----•----------------------------------------------------------------------- Contractor's Name----------------------- - ----------------------------------------------------------- Phone--------- ------------------------- {� Installation will serve: Residence e Apartment House ❑ Commercial ❑ Tr r Court ❑ Motel ❑ Other ❑ ♦ Number of living units: ____/__ Number of bedrooms .1--"Number of baths -_ Lot size ______/D_ ___X._. _Q�_____________ Water Supply: Public system ❑ Community system ❑ Private Er--'Depth to Water Table2?S,,,ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ SandyLoama Clay Loam ❑ Clay ❑ Adobe 2"'Hardpan.0 Previous Application Made: Yes 171No NeW Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu lic sewer is available within 200 feet.) Septic nk: Distance from nearest ell---- --�-----Dista�ce,fVom fo ndation-------- ---- .Mat `;al r, � �} -------------- No, of compartments__ _ __________________Size_st __6__-. J?'�____�Liquid depth_ ..--________Ca acit _tgV-0---------- • n Disposa field: Distance from nearest well-.�� ._Dista6c from foundat�___:� ____Distance to nearest lot line_____ f�_- _ _ ___Length of each line____ rf 9_ �1 � Number of lines-------- ---- -- s�_l�-- Width of trench------�?--�------------____-- _a Type of filter material-__I----�. __�_.Depth of filter material_______��_ ^- Total length_, See pa Pit: Distance to nearest well Distancegffr fo nclation------7&7� __.Distance to nearest lot line__/0_r_. Number of p ------ Lining material_( -_size: Diameter__ �' Depth-a-_ ' _-J �_-_ -------- Cesspool: Distance from nearest well-________-______Distance from foundation___________________ Lining material___________________-__________--___. ❑ Size: Diameter--------------------------------------Depth----•----------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well.------------------------------------------------Distance from nearest building_____________--___________________--__. ❑ Distance to nearest lot line-- ----- --------------------------------------- ---------------•--•--=--------------------------------------------------------------------- Remodelingand/or repairing (describe):--------- --------------------------------•----------------------•------------------------------ ------------•-••-•---------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------•------------------------------------------•-----------------•---------•-•---------•----- ------------ -------- --------- -----------•----------------•-------••-•-----------------------------------•------------------ ----------------------------•-------------------•--------- ----------•---- { 1 hereby ce tify at I have prepared this application and thatthe work will be done in accordance with San Joaquin County ordinances, S+a la , and ules and regulations the San Joa in Local Health Districf. [Signed}..... pli°1 _ - . n-�----- ---- - ---------------------------------------------... Contractor) BP (Title)-_"L. - -0 f'-------------------- : � (Plot plan, showing size of lot, location of syste in relation to wells' uildings, etc., can be placed on reverse side). " FOR DEPARTMENT USE ONLY d APPLICATION ACCEPTED BY-------- -------------------------------- -/ - - - --------••-------------- DATE------- } - -- --r------- I REVIEWED BY------ •-------- --------------- " -- - -- ------------------- DATE----------- ---- -- / --- 7- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------•--•---------------- DATE---------------- ----------------------•------------ - Alterationsand/or recommendations----------- ------------------------------------._---------------------•--•----------------------•--------------------------------------:---------------------- ------------------------------------------ -----------------------•-----------------------------------------------------••--••--------------------------•-----------------••-•------•--------•---------•----------•------••-• + ---------------------------•------•------------------------ -•----------------------------• ------------------- -------------------------•-----------------------•---------------•------------------------------------- -------------------------- ------------------------------------------- -- - - -- ------ ------------------------------ -------------------------- -------------------------------------------------------------- FINAL INSPECTION BY:. --= -- Date--------------- -------------------------- ----------- -•---- 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 FS-9--2M Revised W-2100