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APPLICATION FOR SA � NITATION PERMIT Permit No. (Complete in Duplicate) Date Issued --y/' 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 Odrnance o. 549. JOB ADDRESS D LQCATf --- - - -- ----------- - Owner's Name--- s° ' . --. . .. . = ----... Phone---------------•--=•---------------- Address-------- - �, l ------------- ------------------- ----------------------------•- Contractor's Name - --- - ---•-r-'�-------•---•------•-------- -------------- ------- Phone-_---•-----------------------••- --------------------------------- Installation will serve: 'Residence Apartment House [] Commercial ❑ Trailgr .Court ❑ Mot1l ❑ Other t❑ 9� of living units: __f__.__ Number of bedrooms ._,____ $ _ Number of baths ---,_ of size __------------ Number --x_ - _'-------------------- Water Supply: Public system ❑ Community system ❑ Private Number to Water Table ------- ft.- Character t.Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �Hardpan ❑ �lk r Previous Application Made: Yes ❑ No V New Construction: Yes ® No ❑ PHA/VA: hes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest wellDi tangyg from flOun cion ________-._Ma.terij ____ __c______ [+ No. of compartments_______.__ _._____,�_S•ze1!A -- T «------Liquid Stepth- -Capacity -+ � r Disposal.,Field: Distance from nearest ,ell90 __------Distance from foundation./V Distance to nearest lot line,,,- Y_ e� ] I� Number of lines__________ _ __.__. -_Length of each line_L,"7 Width of trench---------- �l _ +{ Type of filter materi ¢___�__ Depth of filter material____ _ Total length__:_---___ __ ---_ _.-_- I , `` Seepage Pit: Distance to nearest welL�b___________Distance om f ndation- 1'�-`�'Y`_.__: tan fT nearest lot line_,-. _ '❑#"o**w Number of pits------._/ ---------Lining material----l .Size: Diameter___ _' -/ -.__.Depth_..____-_-s Cesspool: 'V Distance from nearest wefl------------------Distance from foundation--------------------Lining material_____-__________________.___________ 1 1 ❑ Size: Diameter ------------ -----------------Depth-----------------<--------------------------=-------Liquid Capacity---------------------------.gals. Privy: Distance from nearest wei4---------------'_--------------------------------Distance from_nearest building-I-------; ---------------------- ---- i ❑ Distance-to nearest lot line_'___ -_-___.r _.___: - ., - - - .1 ----------------- Rema elin,g and/or repairing (describe}: ---- •------------------ ------------------•r�___-__-_-----_-------------------- - ' ;_ I hereby certify that l have prepared this,application and that.fhe work will be done in accordance.with San Joaquin County ordinances, :Sta+e caws, and rule`sJ�and regulations of the San Joaquin Local Health District: (Si(Signe 9 �� x ------------------------------- - -----------------------------------------(Owner and/or Contractor) Plot lan,.showin size of lot, location"of system i.n...relation to wells, Y ;... ------------------------------ ----------------------------(Title----------------------------------------------------------- }` ( P 9 y buildings, etc., can be laced on reverse side). ! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 131 ----------------------------------- ------------ '------------------------------ DATE �� i }� ------------------ --- REVIEWED BY J --------------------------------------------------------- DATE-.--- -- - -------------- BUILDING PERMIT ISSUED----------- _ -- ---------------------------------------------_--------------------------------- DATE------ Alterations and/or rec mmendations:_._- .: __._ '� --------------- - - ---------------- ---- --- ------------------------------------------------------------------ ------------------------------------------------------------------- - ------------------------------------------------ -- �� - FINAL INSPECTION BY:. _------------- ------------------------- Date-------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street k Stockton, California Lodi, California Manteca, California Tracy, California I E5-4-2M , Revisea 1.57 F.P.Co'