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APPLICATION FOR SAN TATION PERMIT Permit No. ...... .:...... � (Complete in Duplicate) Date issued Application is hereby made to the San Joaquin Local Health District for a permit to construct an int t e wor>lLPerein described. This application is made in compliant iti Co�u�nty -dinance No. 549. JOB ADDRESS ND LOCATIO!N. _ - ---------------------- •^ � -----------•------- -:-e...-.-.•. Owner's Na .. ne �� Address........_ r - - ' ------ ................................ Contractor's Name- � ,-Phone----•---____-- ----------- - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel P Other ❑ Q Number of living units: ... ._ Number of bedrooms__Z_ Number ' baths __1-_. Lot size _._�_ __ -- - .�.�_____________- Water.Suppiy: Public system [I Community system ❑ Private epth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand JZ Gravel ❑ Sandy Loam ❑,' Clay Loam Clay ❑ Adobe❑ Hardpan- Previous Application Made: Yes ❑ No New Construction: Yes R<No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspool permitted if public s wer is available within 200 feet.) �istan a fro fou tion__.- 0__._-_-.Mater' L__...._.. Septic nk: Distance from nearest weli_:Z� ". ,1 p [J No. of compartments__.____._ ..._. _53ze. _. - -X __Liquid dept+h__ _ - ___.._......Capacity___..��_(2_ _. Dispos Field: Distance from nearest w istance from foundation_.. Distance to nearest lot lin __ -_-_-___ Number of lines___________ �_ __..___.__ - Length of each line._..--._.�...___L! Width of trench../.._._ . ` Type of filter materi .___--_- epth of filter material..._... ......Total length--- - _______________________ ; Seepage Pit: Distance to nearest well____-_-_-_-_----___Distance from foundation....................Distance to nearest lot line.:............... ( ❑ Number of pits:.....................Lining material-----------.------- --Size: Diameter....................._Depth................................ Cesspool: Distance from nearest well-----------------Distance from foundation.............._.....Lining material..........................__......... ❑ Size: Diameter.............. ----- --De th- ...... ........................,----�- `L'iquid�Capeafy�'. allo! pv _- Distance from nearest well-:____ _____________________a................._Distance from nearest building.......................................... t ❑ Distance to nearest lot line----------------- ----------•-------------- ........ ..........................................................:........ .. Remodelingand/or repairing (describe):....................................••-�•--•••-•--•-...._..-••--•-•----••.....................................................-................... rPw I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ! ordinances, State laws, and rules and regulatnionsof the San Joaquin Local Health District. ---------------- ------•••-•-•---••-----.._...._ ---•-••• ...(Owner and/or Contractor)(Signed) I 9171 B/Showing ..................•----•••...••. ---------•...-------------•--------•-------------•------..........-- ......(Title)............................._...__........-- ------------.. t (Plot pla size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B - =-----------................................__. DATE..r------.....-----------•.---•--•---------- REVIEWED ------_REVIEWED BY............................... --- ----------------------------------------------------------------------------------- DATE----- t. + BUILDING PERMIT ISSUED--------------- -------------------•- ---------- -•-•-•---••. PATE.- Alterations ATE Alterations and/or recomme--ndatio s: _ 4 , ` ..y - ai � �` > .. ...... ------------------------ -r3 l' _.�..._ --•• ------------- tK -...................... ---- }!!!!�'--- l /l-------------- t ------------ - � ._.----_-- -- . - . - ------ . _ ._...- .. .. I. FINALINSPECTION BY:............. ----------------------- ------ ---- 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 ES-9-2M 8-51 Revised W-2100