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FOR OFFICE USE: r APPLICATION FOR SA1�' -1- -�j - _.- (Complete to Dupl., { , (� f _ $Sed _----------------------------------- This Permit Expires 1 Year Frot �F Application is hereby made to the San roaquin-Local Health,Dittrict for a`. ;True. .he work herein described. This application is made in compliance-with-County-Ordinance`No.54.9. , ° F JOB ADDRESS AND LOC -- - ------------------------------------------- ----- - = �Cf�ON:.a 'N .Owner's Name-- -' ----------- ---•--------------------------- -- ------------------------ --- -------- ---- Phone------------------------- -•---•---- Address------ 7 = e' --- ------ ------ -----••-----------•---------------------� Contractor's Name--------- - -- --------------------------- - --- Phone--------------------------- Installation will serve: .Residence Apartment House ❑ Commercial ❑ Trailer Court ❑:: Motel ❑ Other ❑ Number of living units: __/--- Number of bedrooms _--I---,Number of baths 1_--_ Lot size -___-_--_.._--______� Water Supply: Public system ®-1-c—ommuriity system ❑ Private ❑ Depth to Water Table -daft. \�� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ®-'Rardpan ❑ C Previous Application Made: {If yes,date__-----------------Y No Rj-`New Construction: Yes ❑ No'�HA/VA: Yes ❑ No TYPE?OF INSTALLATION AND SPECIFICATIONS: c% (No septic tank or cesspool permitted if public sewer is available within 200 feet.)- � Septi6-Tank: Distance from nearest well-----------------Distance from foundation----------------- 'Material-----------------------------------.------------- 1iXVVf('to No. of compartments--•-----------------------Size--------------------------------Liquid depth-------- ---------------.Capacity----------------------- Disiaosal Field: Distance from nearest/well_.__f.....-.-.._Distance from foundation__2&_!...."Distance to nearest lot line-J`-/-. -f' Number of lines--------1----:/---_-___.---- Length of each line----�� -----__._Width of french- - ---------._.--__-----•-_ Type of filter maferiali/�p� Depth of filter material Total length , ----------- -- F, Plt: Distance to nearest well.-.-- __-_.---------Disfance fr m fou dafion_ � ...-_-_Distance to nearest lot line-__ ---------- Seepage Number of pits`----- ------------Lining maferial_:- _QC_ ___Size: Diameter-37._15... Depth.rza� 0 Cesspool: Distance from nearest well--------------"-_Distance from foundation--------------------Lining material----.-.------------------------------- _-"--. ❑ Size: Diameter ------------------'----------------Depth------ --------------------------------------------Liquid Capacity----------------------------gals. C Privy: Distance from nearest._well-----------------------------------------------Distance from nearest building----------________-------------------_-_-. G ❑ Distance to nearest lot liner------------ -------- ----------------------------------------------- + F I e � r Remodeling and/or repairing (describe)--------- '� ----------- 3--------------------------------- ------------ _ _ ------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------- 4 - ---- ------------*------^--------------- - C --------------------- ------------------------------.---- O'C } --------------------------------------------------------------------------------------'----------------------------------------------------------'--------------------------------------------------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I 7 ',ordinances, State laws, and rules and regulat'ons of the San Joaquin Local Health District. S -------- ---------------------- --- {Signed}----=-----------------;6F,40___- - - �---i -- ------------------� -ten�><or Contract -•--- ------•- ---- ----------------'---- - � � �----=-----�'Title /L _ - j"(Plot plan, showing size of lot, location of system.i lation to wells, buildings, etc., can be placed on reverse side). t � r r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13Y 1�`- - DATE Z ----------------------------- REVIEWEDBY--------------------------- ----- - ------ ----------------------------------------- DATE----------------- BUILDING PERMIT ISSUED-----•--------- DATE Aterations and/or recommendatio �. 1 1 --------------- - ------------------------ -- •s C/L J '� � /- . �d --t------------------- -- -------- r =--------------------------------- --- -------- ----------------•----------------------------------•-------------------------------------------------------------------------- ---------------------------- FINAL INSPECTION BY:._"- ------------- -- --- --- Date---- - ------------- ---------- - -------------- �`, SAN JOAQUIK.LOC AL HEALTH DISTRICT 1601 E.kaeelton Ave. 300 West Oak Street+ 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracyr Colifornia ES 9 REVISED 5-59 3M 3-•63 F.r'.Dq.