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A n . O Permit No. sq r + 4) APPLICATION FOR rSAN1TAlON PE MIT -------- e- (complete in Duplicate) l — X'7 .5� r� p � Date Issued ..........Applica#ion �s he eb IN"t` e San Joaquin Local Health District for a permit to construct and install the work herein described. I This application is made in co pliance with County Or inance N 5j9/ JOB ADDRESS A LOCATION...___ A_- - --- - ------------------------------ Owner's Name... --- ---------- r i Address l I - ----- Phone----------------------------------- ----- --- Contractor's Name-- --------- --- Trailer Court ❑ Mote}I ❑ Othei ❑ Installation will serve: Residence Apartment House ❑ Commercial ❑ ,,,n r �y� Number of living units: VC, ! umber of bedrooms _1-- Number of baths .-._.__ Lot size Depth to Water Table --- ft.• Water Supply: Public system ommunity system ❑ Private ❑ P Y ❑ Hardpan Character of soil to a depth ofA3 feet: S;4_Nev; Gravel Sandy Loam ' Clay Loam Clay Adobe Q P ❑ 1 + { Previdus Application Made: Y s. ❑ No Consfructioh: Yes No ❑ I P TYPE OF INSTALLATION-FANb SPECIFICATIONS: .t •'s. i spr p I (No septic ta- j, .'ces Aol permitted i ublic sewer is available within 200 feet.) t (stance fr foun tion._-1--_ __.------Mat i Septic ank: t'�ista ca from nearest well.... _! Capacity o,oftcompartments------ -- -- ------ +�e - }�_ Liquid dptb = 1i istance from foundation_ - o istance to nearest lot lin } ---- Dispos Field: 'Distance from nearest el - Length of each line..7_Q-""-�-- -ff-----Width of trench.._...__ }------ Number of lines.._.....__ -- length // Depth of filter material.----_--�- --------.To#al length.-----....1_ 11.i/--------• Type of filter'ateri s P l M�. Seepage Pit: 'Distance to nearest well.______Linmg mD}etaai e from foundszie:nDiameter-- Distance toDnep{est lot ine--_----- ❑ Number of pits. .. els. ° 'Cesspool: Distance from nearest well from foundation....................Lining material------------------------------........ Depth- Liquid Capacity----------------------------g k ❑ Size: Diameter------------•------------------- { building----------------------------------------- Distance€ Distance from nearest well.__..-.-..._..--.- -----------------------------Distance from nearest bui in - ❑ rt i ,meq dhstance_+m•near.est lot line ---• ----------------- ----------------------------------- Remodeling and/or repairing [desaibe '---- —----- -- -- ( --•------------------------------- r --- --------------- ---------- c = ..' ----- ------------ --------------------------------------------------- t �i3 . ................................_.-._____•.. ......._....___•_-•_._•_•- ---._.___•__•_ . -------------------------------------------- ----------------------------------=-------'------__.---- ..---.._........_---•-----. --- ..--.-------- ------ -------------- --------------- _-_.-....-_.-.. 1' I hereby certifyjthat 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. (Owner and/or Contractor) (Signed) c� , . '3 l --------------------- - �-+-� (Title) �-� $Y: =----------------------- a------------ (plot plan, showing size of lot, loc$tion of system in relation to wells, buildings, etc., can be placed on reverse side). Lei FOR DEPARTMENT USE ONLY ri ° DATE------------- --------------------------------- APPLICATION ACCEPTED BY.-- --(-- --- ------ ------------------------------ DATE -------------------------------------------- REVIEWED BY------------------------------- --- - ---------------------- - _ _ _ _ _ - BUILDING PERMIT ISSUED-------------- - ------------------- ------ -------------- DATE --------------------------------------------------- - Alterations and/or re ommendations:------------------------ -- --•---- --••--------•---------•-------------------------------- -- = ---------•-----•----------------- ------------- ----------------A-------------- ---------------------------------- ------==------------- ---------- -•----- --------------------- --------------------------------------------------------------- FINAL INSPECTION BY---------------------------------- --- ----------- ------- - - - -- :-------- SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C" Street 130 South American Street 300 West. Oak Street Tracy. California Stockton, California Lodi, California , Manteca, California ES-9-2M 10-52 Revised W-2100 �--