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FOR OFFICE USE; vP /Q/9" B --------------------------------------------------------- APPLICATION FOR SAMITATION PERMIT Permit No. ____________________ ----------- ----------- -------- ------------------------ (Complete in Duplicate) Date Issued --- ------------------------------------------------ This Permit Expires 1 Year From 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----- --11q------- .---�C_.��/# Owners Name---------------- 1. / -- ! ? ��1,° '-------------------- ------------------------ ------- ----------- Phone_ .a - -•---- --`/��-��------- Address-------------------- ------------ --��----•-------------------------------------•------------------------------------------------------------------------ Contractor's Name----_ ________�_ ____-____-- PhoneJW",' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot I ❑ Other ❑ Number of living units: J---___ Number of bedrooms ___ Number of baths __, Lot size .__ _: ._---___-________.-__-._ Water Supply: Public system ❑ Community system ❑ Private V?-*f)epth to Water Table - it. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [] Clay Loam [YGIay E] Adobe [] Hardpan E]Previous Application Made: (If yes,date-------- --) No New Construction: Yes No PR"' /VA: Yes DPW-<o 0' 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__`5d---/Distance from foundation__-f ___________________ ❑� No. of compartments.-._.__..:�77-`----------- depth--- J.-_ Capacity__/5_ _V_-(� Disposal -eld: Distance from nearest well -5V------.-Distance from foundgtion__ _J_---------Distance to nearest lot line__f _/_____ Lengthiof each (ine �__�'o---�--_=_ Width of trench... '�---_------ Number of lines----�-------------------------- --- -- Type of filter material________________-_`___Depth of filter material------e� ---_Total length------- ____f__ -'/--- Seepage'Pit: Distance to nearest well----AR.�__ ----Distance fro�oundation__y A___.___.Distance to nearest lot line___�`Q_.______ [ Number of pits-------'�_----------Lining material!.,;%/, - ,_.Size: Diameter._" Depth__ . _.'________________ 0 r Cesspool: Distance from nearest well______-_________Distance from foundation------------------- material__' `' .__ __-____-______ Size: Diameter-------------------------- ----- �'- --------------- ----------- ------- -------------Liquid Capacity---------------------------gals. (� Depth-� Privy: Distance from nearest well------------- ell1,,_______-____t_________ ______Distance from nearest building------------------------------ ❑ Distance to nearest lot line------------t---- - --------'---------------l------------------------- -------------------------------------------------------------------- t ► r, Remodeling and/or repairing (describe):____- -�1fz1i� ___"" r� f ------------------------------------------------------------------------------------------------------- 1 ---------------------------------- -------r--------------------------- ----------------------------------------------------------------------------------------------------------------------------------•------------------------------------r-------- - ---------------------------------- - ----------------------------------------------- -----•--------------------------------- ----------------------------------------------------------- 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-r es and regulations of the San Joaquin Local Health District. (Signed) ne .and/or Contractor) t B _ ' -- - ---- ( ) � t--------------- -------------- Y -., .._.._ '�Z.l�-�� - Title (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be' placed on reverse side). FOR DEPARTMENT USE ONLY ,-"'` - '-------------------- DATE- +� �J �� APPLICATION ACCEPTED BY---- ----- --------- - --------- --------- -- ----- -- /- �- ---- REVIEWED8Y ------------------------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED---------------------------------------------- ------ ---------------- ---------k ----------------- QATE - -------------------------------------------------------- Alterations and/or recommendations:=�_-f.-�__1_�__.�-- S=-- ""1=-= -------•• - - --- -------- ` -------- ------- ---------------------------------------------- J-------------------- ------ ------------------------------------------------------------------------------------------------ --- r F€NAL INSPECTION BY:.--- L�`?" rNJOAQUIN -------------- A ._. Date /--�f LOCAL HEALTH DISTRICT 1601 1.Hazelton Ave. 3k Street 124 Sycamore Street 205 West 9th Street Stockton,California ;,Lodi,California Manteca,California Tracy,California F.P.CO.