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FOR OFFICE USE: ----- - a ....___---------- -- ------------------- ----------- - APPLICATION FOR S`ATII�'ATION PERMIT Permit No. ........_�....... •--------=---- -- -------- ------- ------ (Complete-in Duplicate) This Permit Expires 1 Year From Date Issued 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--- __ ---------27 Owner's.Nem..e----=----=---=------------------•--•--- _ .. ---------------•----.. ---- ----------------------------------------------- Phone------------------------------------ Address -----------------------•----------- ------------------------------ --------------•---•--------------------------------•--•--•------ ............................. Contractor's Name--------------1_`--------- --------------------- ----------------------------- ----- ---- ------------- •-----------------------•-------- Phone....-- ----------------•--•-----••- Installation will serve: Residence- Apartment House ❑ -Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I..- Number of bedrooms-__ Number of baths-.'___ Lot size _ -K___ --- ------- •----------------------- Water Supply: Public system (� Community system ❑ Private ❑ Depth'to Water Table ______ _ ft Character of soil to a depth of 3.- feet- Sand ❑ Gravel ❑ Sandy Loa fX Clay Loam E] Clay ❑ Adobe E] - Hardpan E] Previous Application Made: (If yes,date_-................. ) No ❑ New Construction: Yes ❑ No ❑ FNA/VA; Yes ❑ No 0 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �� a Septic Tank: Niostaof compartmentst.well .._tel Indation___________________ Materially.-. i '�' p E�_-_Distance from fou f___.__Liquid depth_____ ' ` Capacity__. _. Disposal Field: Distance from nearest well....----.--------Distance from foundation--------------------Distance to nearest lot line.__._____._.._-_ ❑ Numbor of line s.----------------------------------Length of each de_ ---------------------------Width of trench.-- ------------------ Type of filter.,-material---------- --- ----------Depth of filter material----------_------------Total length------------------------------------------ Seepage Pit: Distanco to Weare wel1�/�/'.,kv:�_____Distanc rom foundation_--___t._!yt'___ . ist ce to nearest lot line.... .3� i Number of pits--_ �_._----_.-.__Lining material. -_i_- Size: Diameter ___.._.__ Depth_,1 I___________________ r Cesspool: Distance frorri• nearest well ________________Distance from foundation. Lining materiaf----------------------.-------------- . • 1 ❑ 5¢e: Diameter- -- --------- -- -- --=?�----------Dept h- ---- -------:-:--'-------- ---- ---------------..Liquid Capacity--- ------------------------gals. Privy: Distance from nearestiNell-.,---- --------------------------------___ Distance from nearest building..----------- __------------------------ ._ ❑ Distance to`nearest lot line - ---------------- Remodeling -------------Remodeling and/or-repairing.[describe) ""` ---------------:-------------------------=------------- ---------------•--- �, i I ------------------------_-------_----_---------------------_------------- -------------------------------------------------- I hereby certify that I haveprepared 41 is application and that the work will be done in accordance with San Joaquin County ordinances, a s, an rule re ions of the San,Joaquin Local Health District. (Signed]_ __ 1 [ wner and/or - - -------------------- - ---------- ------------- ----1--------------------(Title)-----------------.---------------------- - --------------- (Plot plan, showing size;f lot, Location of system in relatioto Iwells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---.--^- __- � ----- ----=--- ------ ----- DATE----- - `I$�-�-7--- -------------------- - - REVIEWED BY. - DATE BUILDINGPERMIT ISSUED-- :-------- -------------------------------------------------------------------------------- DATE------ --------------------- Alterations and/or recommendations:---------------- - ------ ........... i -------------- -- ------------ --------- ------------------------------------------------------ --------- ------------- ------------ -------- ---------------------------------------------------•------I- ------------------------ -'-------------•-----------------------•--- •-------------- t --------- ... FINAL INSPECTION BY:. ._ - ` ` = --- Date.- '---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California 11 Tracy,California E.H.9 2M 1-67 Vanguard press