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FOR OFFICE USE: 2 xv---- --- APPLICATION FOR SA+11TA11ON PERMIT Permit No. I (Complete in Duplicate] Date Issued / _- - ------- ------- This Permit Expires 1 Year 1From Date Issued ------------ ------------------------------------------ - is hereby made to the Sen Joaquin Local Health District for a permit to construct and install the work herein described. Application Y This application is made in complian6e with County Ordinance N,o�,.�5f4 . ESS AND LOCATION_ "I" 1 ---- -------- ---- JOB ADDRESS hone------------------------------------ -------- _--- -- - -•_ •-------- -------•----•----•------- Owner s Name ------------------- Address__.__.__.__." II Phone--------------------•-------------- ------------- '�r-"" Other �•--- - -- - � Motel ❑ 0 Contractor's Name-------- Commercial ❑ Trailer Court ❑ t artment House ❑ s Installation will serve: . Residence �' Ap l .__ --------------- r Number of living units: __/-. Number of bedrooms __ Number of baths __�__ Lot size _- I Public system Community system ❑ Private ❑ Depth to Water Table -_.__.- ft. Wates SupPy: Y Clay Adobe�ardpan ❑ Gravel ❑ Sandy,Loam Clay Loam ❑ Y ❑ No 0—t Character of soil to a depth of 3 feet: Sand ❑ New Construction: Yeso ❑ FHA/VA: Yes ❑ Previous Application Made: (if yes date__.._-._-.- 1 NO f TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool"permit#ed if public sewer it available eai orrlefoun�dafion0_`et)rf Material_ �--- -------" �� Septic Tank: Distance from nearest well-_ ' ----- s��-3 _Liquid de th_ � Capaeity_ � � ---- --------------Size---------------- - a P.f No. o{ compartments_.. /-----------.Distance to nearest I� line_ -------- lf ------Width of trend-�------------------------ pisposal Field: Distance from F nearest well._ '_ -Distance th o{reach line om oun at -�-- \, Number of lines t-- g //�+ -_Tota4 len th _v� V De th of filter material-__/- "_"" -- 9 Type of filter material`�e__ p ©/ ��nce to nearest lot Ijme_ _____"---- -__Distance fr #o dation_- ------• Seepage Pit: Distance to nearest well_____.._'" ---- Size: Diameter---------- -----Depthl' ��-- Number of pits----f--------------Lining material_ -- Distance from nearest well "__':-----Distance from foundation___-__"---- Llquid Capacity_..__.______ gals. + Cesspool: ii ------- ❑ Size: Diameter---------------------- ------ Depth - _ Privy: Distance from nearest well-------`--------------------- --Distance from nearest building----------------------------------------- Privy: --- -------- --------- ---- ❑ Distance to nearest lot line------.-------------------------------------=---------- - I — -------------- -- ------------------------ - ------ --- Remodeling and/or repairng (describe:______------------- - ---- ------- --------------------------- ------------------- -----------•------------------------------------- ; that ! have'-------------'-------------------- y I hereby certify 'prepared this application and that the work will be done in accordancet n County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. -- -------- ------------- ---- - -- ' ontract � o(Signed)-------------------------- ---- --------------------(Title)----- G� -----------------By: h _-__-- g P(Plat plan, showing size of.lot, location of syst to relation to wells, buildin s, etc., can be laced on reFOR DEPARTMENT USE ONLY - ------------DATE-- Jam- ----------------- ----------------------------- APPLICATION - APPLICATION ACCEPTED BY_ _..._-"" -- ------------------- - ----------------------------------------- DATE-- - ------ ----------------------------- - REVIEWED BY DATE----- BUILDING PERMIT ISSUED-------------- -- -- ------ ------��--- -------�---- :----- -----__----:•------ ----- ommendations:___ .-- X .OPS D�_' �_ - --------- Alterations and/or rec -------------------------------------------------- --------------- ----------------------------------- -- ---------- --- -------------------- f Date---------- ------ ------ -- -- --------------- ---- FINAL INSPECTION BY:__ ." = - --- --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 124 sycamore Street 205 West 9th Street 1001 E.Haselton Ave. 300 Oak Street Tracy,California Lodi,,CaliforniaCManteca,California Stockton,canfornia