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i APPLICATION FOR -IRRITATION PERMIT Permit No. (Complete in Duplicate) Date Issued --- O&f l31 - nom Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descl ibed. + This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCA ION_______tt ___ Owner's Name---------------WM & Vernice ce �anllk -_ ------••------- -------------- ------------------------------- ------------------------------ --- ------- Phone' V2283.------------------ Address-------------------------- .---------------Address•-------------------•----- Bx9 Contractor's Name-------------- el t a-------------------------- ----------------------------- -----------------------•-------------------------------- Phone..9----3�--------------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel D Other ❑ Number of living units: _-_-- Number of bedrooms ---�_- Number of baths -;k--.. Lot size Water Supply: Public system ❑ Community system ❑ Private © Depth to Water Table . ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoamQ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: 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---6 ------Distance from foundation [� foundation_--- ----__---M aterial_�- CIamt I Yr --------- --------------------- No. of compartments----- 2----------------Size -6 ' > Li id deth---- r& _--- - ; - 5 Capacity-----8n Disposal Field: Distance from nearest weli_-.79.1------Distance from foundation-------.1-_�-------Distance to nearest lot line--5-t ® Number of lines---------1-----------------------Length of each line-----SOT----- f -------- --------Width of trench------?--___--- N ------------------ Type of filter material -_-----r'Oc _____Depth of filter material----;0 ---------.-Total length----------59--------------------------- 1W Seepage Pit: Distance to nearest well__-.-Z�O.fDistance from foundation----1-9_---------.Distance to nearest lot line------ -1------- Size: Diameter-__-- 1 f ® Number of pits ---------�---------Lining material----briC�----- -�-- ------------Depth----��-�'.,�---'---- 1 I Cesspool: Distance from nearest well_----------------Distance from foundation--------------------Lining material-----------------------_-_�.__, El Size: Diameter--------------------------------- ----Depth----------------------------- --- -------------------Liquid Capacity ---• --9als.-- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building� ❑ Distance to nearest lot line___________________________ _ Remodeling and/or repairing (describe):..........I1CW -------•---------------------------------------•--------------------------------------------•------------------------------•------------------------•--------------------------_...---------------------------------- 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)------------------- r3 �_______-_-- --(Owner and/or Contractor) By----------- -------------- Perry T, qy th ari. ------------------------------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED Bl DATE _------------------------------------------------•---- REVIEWED E I IS E � ------------------------------------------------------------------------------ DATE---fs ---- BtJILDING PERMIT 15SUE0. ----------- ------------------------------------ ------------------- DATE------RN 6.------------ Alterations and/or recommendations:---------------.-- -- ----------•-------•--------- ••-----------•--------------------------------------------------------------------------------------------•-------- ----- ---------•--------------------------------- ---- --------------- ----------- ------------------- -----------------------------------/- � F1NAL INSPECTIONBY:. Date---------- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-2100 .{