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FOR OFFI E USE: f ------ --------=r7/-�---- :----- s��---- Permit No. .. . ��'3 ----- --------------------- APPLICATION FOR-SA.�IITATION PERMIT' _ ----- - ---------- - --- ----- ------------------------- (Complete in Duplicate) L- foJ Date Issued `�`_�-_...____-. _- ------------------------------------- This Permit Ex Cres 1 Year From Date Issued JSa -I S,=9- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein ibed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-------------- / 7------ -------------------------------------- Owner's Name - Phone_ /--- - ---- - --------- - ---------- - Address_________ - p ---____---------- - - Contractor's Name------------1T____-------- ----- Phone---------------•---._-------•-•---- Installation will serve: Residence Apartment House ❑ Commercial E] E]Trailer Court Motel [I Other E] �D/ Number of living units: __/_ Number of bedrooms __Number of baths __/-- Lot size --------------------- __./_ - ---------------- Water Supply: Public system ❑ Community system ❑ Private epth to Water Table r_a._ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ! ardpan ❑ Previous Application Made: (if yes,date--------------------I No 011'_New Construction: Yes [A,-40❑ FHANA: 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-----_-----------Distance from foundation--------------------Material------------------------- .._______-------_..__. No. of compartments-- ------------------- Size--------------------------------Liquid de%h------------------------- Capacity----------------- -- Disposal Field: Distance from nearest well.,. v__ Distance from foundation---1.4�----.---Distance to nearest lot line_____...- Number of lines------------------- - �--- -Length of each line------------------ ------- Width of trench--------- f.------------------ x Type of filter material- �e ----- ___ ___�__5-'�/.Depth of filter material_._.__/e_ Total leng#h-_____________ _-��---!!- - - S Seepage Pi : Distance to nearest well------ ---------------Distance from foundation--------.------_-__.Distance to nearest lot line_-__..__.._---._ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth---------------- ------ N Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-...---_---_____-_- ❑ Size: Diameter-------------------------- --Depth-------------- -------------------- -----------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well--------------------------------------------- ---Distance from nearest building-------------------------------------- -- 0 ❑ Distance to nearest lot line------ ---------- - -- ------ ------------- ------------------------------------ ----------- ea Remodeling and/or repairing (describe)--------- - ------ -------------------------------------------------------- --------------------------------------------------------------------------------- -----------------------------------------------------------•-------------------------- -- ------------------------- -------- ---------------------------------------------------------------------------------------------------------------------------------------------•------------------ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State Iaw3, and rules and regulations of the Sarr Joaquin Local Health District. Owner and/or Contractor (Signed)----- --- -�u--��---��-- -� - ----- --- ------------------------ -- -------------- ------------------------------------ ( / Qy -------------- . 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---- c' . L ------------------------------------ DATE---- ---------- REVIEWEDBY------------------------- ------------------------------------------ --------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------ ---------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:--------------------------- ---------------------------------------------------•-------•------------------------------ -------------------------- --------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- -•----- FINAL INSPECTION BY:---- _ ----------- -- ------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT. 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C C.