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FOR OFFICE USE: . - . ._, .-.-- ______________---.------.---.--.--______----_---------- APPLICATION FOR-SAWATION 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 tFie work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS A LOCATIO ___ aI ,� _ _ _-- _-- �,�fz--- �-- -- --_-- -- Owner's Name__` tQ�- _ - - - - . = Ph ne Address_.5e4_- n �_.�- 9.� � � .�C- ------------------------ Contractor's ------------- --- Contractor's Nam - - --------- --- ---- -- AI ----- � Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other F1 Number of living units: __/_-- Number of bedrooms 3--_ Number of baths _A!:�'Lot size /,, __o.. ........... ,Water Supply: Public system ❑ Community system ❑ Private`[% Depth to ter Table -_-- -- ft. Character of soil to a depth of 3 feet: Sand [] Gravel ElSandy Loam Clay Loam El C� E] Adobe E] Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes 2?/No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T Distance from nearest wel �______Distanc�e InAfou d �pn_�_ __.______.Mat riaL_ '_ ____ _ _ _________ _____________________20, No. of compartments--�1�_.--.-_---_____Size_4J _ fO---Liquid depth_-- -----Capacity---Of7---- Disposal Field: Distance from ne` est welt;. ...t...Distance from foundation_-Z.4.1- Distance to nearest lot lir ____A _._. Number of lines-J, _- __._ .---_Length of each line �t 1---�d r Width of french - ��'�r__________________� N Type of filter maters -._-Depth of filter material----.-/9.__.....__Total length_-_---f-�i-Q---------------------- Seepage ------------- --- Seepage Pit: Distance to nearest well---------------------Distance from foundation--------------------Distance to nearest lot line----------------- � ❑ Number of pits------------- -------Lining material._._-- --- Size: Diameter----------------- - ---Depth--------------------------------- I Cesspool: Distance:from nearest well-----------------Distance from foundation------------------- Lining material-_--------_----- ---------- -_._-. Size: Diameter----------------- --------------------Depth----- ---------------------------------------------Liquid Capacity_-------------------------gals.�0 7 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building._ _---._--___-_-_--_----_-__-.-_--..._.7( ❑ Distance to nearest lot line-- --- -------------------- ----------------- ------------------------------ ----------------- --------------- ------------ ----------------- 0 I Remodeling and/or repairing (describe)---------- - --------------------- -------------------------------------------------------- ------------------------•------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------fid J -------------- --------------------------------------•-•---•-------------------------------------------------------- ------------------------------ - -------------Q. ---------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- I hereby certify that I have prepared this applicatio and that the ork will be ne in accordance with San Joaquin County ordinances, St a e a s, rules a regulations an Joaquin a1 Hea strict. (Signed --- - -------------------- --'W- --- - I - - ------ -- -- ---- . --- - - w Contractor) --------------------------------------------------------------------------------------- ------ c �_Jlfe] (Plot plan, showing size of lot, location of system in relation o wells, buildings, etc., placed on reverse side. x FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------ ---=--------------------.1 . -v ATE------ -----I ----- REVIEWEDBY------------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED----------------------- - DATE.> Alterations and/or recommendations:._.___-:.- � :_a _; ------------------------- -------------- ------------------------------------------------------ -------------------------------T-------- ,: ----------------I--------------------------------------•- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------I-----•--------- --- ----------- ------------------------------------------------------------ - ---------- ------------------------------ --------------- -------------------------- --------------------- - - -------------------------------------------------- -------------------- - ------------------------------------------------------ ------- ------ --------------------------- ---------------- -------- FINAL INSPECTION BY: - - Date--------- �= 7-� -�� 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,C'iolifornia Tracy,California F•.R.c o. f 1