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FOR OFFICE USE: � � mr/� ------------------- Idll --------------------------------------------------------- APPLICATION FOIr'SAKTATION PERMIT Permit No. ..... .-C....___..-_ I (Complete in Duplicate) l° __..___. __. This Permit Expires 1-Year From Date Issued Date Issued ______ ___ _________ 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. 549. JOB ADDRESS AND LOCATION__-oZ�-- -- ------------••----------------------------------------------------------------- ---------------------------- Owner's Name-- '------1� ---- Phone Address_____________ Contractor's Name ----•-` x r-------------- ----------------------------------------- - .._._-----------.._- Phone.---- ---------------------- Installation will serve: Residence [!T-Apaitmenf•House ❑ Commercial [-]-Trailer Court ❑ Mooteell ,❑ [IOther Number of living units: '(�_____ Number of bedrooms -3.- Number of baths _0-Lot size ___f_" ________________________________.__ Water Supply: Public'system ❑ Community system ❑ Private [ Depth to Water Table __loft. I, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ .Clay Loam [j Clay E] Adobe E--Hardpan C]Previous Application Made: (If yes,date--------______.___.) No [� New Construction: Yes ❑ No U FHA/VA: Yes ❑ No ®-� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted'if public sewer is available within 200 feet.) Septi Tank: qs Distance from nearest well_________"_______Distance from foundation________._- �__...Material________________________________....._.__._____. 0 No. of compartments. ----1--- --- -----------Size---------- --------------------Liquid depth------------- - --------Capacity-----------•----------- N Dispo r l Distance from nearest ell_4_h--------- Distance from foundation__7 _�.3__._.Distance to nearest lot line__-___.... Number of lines------- ---------------�__._-_ --Length of each line---3_.0.--7---- ------.Width of french---------- Type of filter-materia�___1_tit,�- - of filter material---/r_ __________Total length___.__3[�-_-_----------------___--____ Seepage hit: Dis#ante to nearest well_.�CD_.____.. Distance from foundation____,e Q_!___..Distance to nearest lot line_ t5.V._____- -- ! •� i 3 Depth r. Number of pits._____,...- Lining material___-lt.C,. __;.Size: Diameter__.._ __ Cesspool: Distance from nearest well_________________Distance from foundation_____._.....___._..Lining material_._.____._.___..____.________-_______..� `+ ❑ Depth----------- -------------------------------•-Liquid Capacity----------------------------gals. rp Size: Diameter--------`---------- ------------- - Privy-. Distance from nearest well----_ ------------------_----------------------Distance from nearest building--------- ------------------------------ _k ❑ Distance to nearest lot line----------------------- ---------------------------------------------------- ----------------------------------r------=--------------------- Remodeling and/or repairing (describe) - F- -----------------•----------------- -•------ ----------- ----------" t I = -------------- .1 r I hereby certify A'at I have prepared this application and that the work will be done in accordance with San Joaquin County ' ordinances, State laws, d rules and�qfions theSan :.loaquin Local Health District.(Signed) t i------------------------ ---------------------- ----------------------(Owner and/or Contractor) 6 F (Title)_. y '-------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FOR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY--- ---- --- -- -- ---- ----- - ------------------ DATE----- - ---- ----h---- ------- -------------- REVIEWEDBY---------- i----------------------- ----- --- ----------- -------- - --• -------------- ------------------ DATE-- •---- ------- BUILDING PERMIT ISSUED------------------- DATE------------------------------------------------------- -------------- ----------------• ----------- ----- ----- ------ Alterations and/or recommendations:____1�`_." . .�_____l�.�.�,�. .__.__---------------------------- ----------------------------------------------------•------------------------------------ --------------------------------------------------- --------------------•----------------------------------------------------------- u t t 5, ------------------- ---------------".............._____....___--------"______.._..------------------------_----------------------------------------------.-------------------------------__.__------------------------ ------- / L��.. Date -FINAL INSPECTION BY:..... . _._ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.ffaxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi,California Manteca,California Tracy,California A