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APPLICATION FOR SAS ITATION PERMIT Permit No. a ^K. ate in Duplicate) Date Issued ......�A3� _- (Comps Applica+ion is hereb� madeTO he'�ari Joaquin Local Health District.for e permit to construct and install the work herein described. This application.is made in compliance with County Ordinance No. 549, U ZZa� ' JOB ADDRESS A ' OTION-_ ----- ` Y Owner's Name ... " - .._ Address _ Ahone_ x ------.....a /� -----•------------------------------- ------------------------------ Contractor's Name-------- ----- - ------------------- --------------------------. Phone-=- Installation will serve: Residence ki—,Apartment. House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ x Number of living units:�/___ Number of bedrooms___ Number of baths Lot size ___� .�-.__ _=_�_ -------------- Water Supply: Public system ❑ Community system X. Private ❑ Depth to Water Table"d4 ft. Character of soil to a depth'of 3 feet: Sand.❑ Gravel ❑ Sandy .Loam ❑ Clay Loam ❑ Clay ❑ Adobe 91 Hardpan ❑ Previous Application Made:,.Yes ❑, No W New Construction Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ; (No septic tank or cesspool permitted if public^J suer is available within 200 feet.) Septic Tank: Distance from nearest well__OV•0-----Distance from foundation__. -----Material---C!:;7 - ------------ No. ------ . No. of compartments __ _______.5ize__ _..Capacity .� p ..ate----- �_��_..Liquid depth.--��.--- - -----��-d�------- O i Disposal Field: Distance from nearest well_�Q istance from foundation_��_____....Distance to nearest lot line, -r___ N rr Number, of lines---------- -___--__R...... Length of each linedv9_ O. ._ Vidth of trench _- - J If ( -�-----`---------- Type or,filter material__ �...____R:-Depth of filter maferial__.Ax----.___.Total length___Z11--—`a-_____'------------- Seepage Pit: v Distance to nearest well..;, .---Distance r foundation___ __�____Distance�o nearest lot Zine___ Number;of its.-. ____._Linin materia l_ �_`iie-_Diameter---- < Depfh_.___Zk_4 - Cesspool: Distance from nearest well_________________Distance from foundation-__._---------------Lining material--__.__-_-_--_-_._.____.__-__--____ ` ❑ Size: Diameter----------------- ------Depth--------------- __Li uid 'Ca acit ---------•--------------- als. - Privy: Distance from nearest well_____........................:---,r--_.__.___._Distance from nearest building-._________._____--..-_--------___-_---. ❑ Distance to nearest lot line------------------------------------- -------------•------------- ---------------- ----------- Remodeling and/or repairing (describe):__.._-_:__ � t _________---•------------------------------------------------•----------- ------------- --------------- ---------•-------------------------•--------- ••-----------••---------------•--•t-----------------------------------------------•----------•------------•----•------- ------ 1 ordinance 5t ws and rule n r � ---------------------•---•-------------------------------`------ -------------------------------------------------------------- I �- •--- ----------------- ------- ---------•----- -------------- -----------•----------- q Y hereby certify that I have prepared this application and that the work will be done,in accordance with San Joaquin Count s, sad egulations of the Sari Joaquin Local Health District. k ----- - - --- ----- -(Signe(Signe ---- - ------- ----- - + --- wner and/or Contractor) B (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 BY----------- - DATE REVIEWEDBY------- ------------------------------:-------------'---- ---- -•---- ----- ----------------------------•------------- DATE------- ---•------- ------------- BUILDINGPERMIT ISSUED---------------------------------t------ --------------------------------------------------------- DATE----------•-------- Alterations and/or recommendations-------------------1----- --- ---------- ------------------------------- ---------------------------- AS---------------------------- -------------------------- _ __. ._ ._--_- _ ------------------------ _-__•..-__. _______________ - __________ - ---------------------• ---------------•------------- '" -----------•-----------•-•---------' ___ 4�+.____ --------------------_______•_.-_____..__.___ .._____.._______..._-____-_..__.___..______-___._____.____ _.__._____.________.___.._.-__-_--.-_--._______________._____---------______.____. .L FINAL INSPECTION BY:' r ,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 E5�9 145446 ATWOOO T