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.. APPLICATION F0R..-SANI'f ► 101 PERMIT )Permit No. 41 ___-___ �e `(Complete,in:Duplicatel — ,=� E 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.- _ ___ ________ _ ------------- -- --- -1 Owner's Name-- " �' ----•----- yy�� ---- -------- --------- -------------- Phone- -----------------•---°------------ �y Address-------1�-...� r'? :._ T, - -------------------•--------------------Phone-------•----•--------------------.. Contractor's Name------ ------------•-•------- Installation will serve: Resides Apartment House ❑] Commercial ❑ Trailer Court E] Motel L] Other E]Number•of living units: :--- Number of bedrooms -"(//- Number'of baths Lot size ____-___ Water Supply: '-Public 'system~;O Community system ❑- Private ['Depth to Water Table _/a ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ , Clad❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ Not New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: .- �� `� (No septic tank or cesspool permitted if public sewer,is available within 200 feet.) r� Septic T nk: istance from nearest well_________________Distance from foundation--------------------- Material------------------ 0, -of __-__-__-_--__o. .of compartments---- --------------- -'- Size% -------------------------------- Liquid depth Capacity 7 I Disposal Fiel R: a from nearest eiL_.-!Zs- ."Distance from foundation__ Q�-____.Distance to nearest lot li ❑ er of lines----------1_---- ---- Length of each line----------- ---� -.------Width of trench----- Z- ---------------- e of filter material__ '� }epth of filter material------/-,�r«--7ofal length-----------_ Z - -----------••---- pe4age Pit: Distance to nearest well----------------_-_---Distance from foundation______________:-___Distance to nearest lot line----------------- El Number of-pits----------------------Lining. material-----------------------Size: Diameter---------- ------------Depth------------------------ .5+ Cesspool: Distance from nearest well------------- ----- material-------------------------------_____ ❑ Size Diameter- --- - ---- ----------Depth-------------- - �• � ---�•�:-..-4��,�_ ._ 3 -- ------- --'--- ------- ---L;quibd Capacity ------------------------a acit . - al Privy: Distance from nearest iveil ____. 4 -�-------- ------Distance from.nearesf'Jui ing--__-____-__-------- ❑ Distance to nearest lot line - - ---------------------- Remodel' g and/or repairin (:describe]:- ------ ---- ---------------T--••-- _ 1 -4 __ " - -- - - --------•• + '_ -•---•---- .d.�• ------ ----- ---•--------------•---------------------- -------- I hereby certify that I have prepared this application and. that the workrwill be done in accordance with San Joaquin County ordinances, State laws, and rules an regulations of the San Joaquin Local'Health District. Si ned -----------------------------------(Owner and/or Contractor) By: ---------------------• ---------------------------.,�-�--- ---(Title)------ - -------------------------------------------- -------.. (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_----------•----- . -----�:- REVIEWED BY------------------------------------------------------------- -- DATE------ - -t BUILDING PERMIT ISSUED -- -------------- ------- DATE.--.-./ - --------------- --and/or recommendations----------- ----------- ------ --__------------------------------ -----------------------•- -----------------------•------- -•----------------- •--•----•-•----------•----••-•----------- ----------------------------------•---------------•--------•--------•--i----- ----------------------------------------- --- -------------------------------- --------------------------------------------r--------------------------------- -----------------------------•----L/-------------------------------------------------------------------•----- ----------------------- --------------------------------------------- FINAL ------------ ------------------------------- FINAL INSPECTION BY------- ---------- -----=--------------------- Date---- -----"C,---- -------- -� ----------- 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 ES-9-2M t0-92 Revised W-2100 k