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,-UKUt-"U: U5E: y eg ----------------V-- ---------------------------_ ...... APPLICATION FOR SA40ATION PERMIT Permit No. -- ---�� -•.J� ----------- -•-------------------------------- -------- (Complete in Duplicate) /_� ----------------- This Permit Expires 1 Year From Date Issued Date Issued A y Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the workh rein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AVP LOCATION_�S 4___ / r Jr ----- ��!! --------- — �- Owner's Name--- ._-lr �• Address----_I.0 � -•_-•- -... Phon -----•-----.. :... --------------------- e..................................... Contractor's Name.. .. ---------T ------------------- Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .._--_ Number of bedrooms-3--- Number of baths I_ Lot size _f,:3 -s _ X_-.hr' -_7............... Water Supply: Public system ❑ Community system �rivate ❑ Depth To Water Table -4R ft. C Character of soil to a depth of 3 feet: Send ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe CJ Hardpan Previous Application Made: (If yes,date-- -----------------) No [ New Construction: Yes �o ❑ FHA/VA: Yes PErNo ❑� 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 ` ------Distance from foundation7(J..--------------Material-----..._--------------------------------------0 Cb No. of compartments-- Sixe SKID-------Liquid depth__,------. Capacity-j �[ Dispos Field: Distance from nearest well -.- ------- Distance from foundation..,(P--f.........Distance to nearest lot line.7�...... �p Number of lines----------------------- -- ...... of each line.---_---- r---•------Width of trench.---1y-yl Type of filter material.....%eSk-------Depth of filter material---42.` _ _ -_...-----------... '-_---... Total length ._ -------•-•-•------ el Seeps Pit: Distance to nearest well-___-.' ._-•-----Distance om foundation---Z ......-_Distance to nearest lot line--16 1...... Number of pits-----._-_A--__ ---Lining material-------e0---------Size: Diameter---- Depth---------- Z.±r'--_-_.----- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material..--.--------_------------..-------•- y ❑ Size: Diameter------------•------------------------Depth---------------------•------------------------------Liquid Capacity---------•-••--------.------gals. Privy: Distance from nearest well----------------------------------------- -------Distance from clearest building---------------._.-.--__--.-_ El Distance to nearest lot line----- ---------------------------------•-------•----------------...._.. Remodeling and/or repairing (describe):-- --------- ---------------------------- •-•- - ---Ai� -------- hereby certify that 1 have prepared tho and th the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulaan Joe uin Local Health District. (Signed)---------------------------------------------------- -------- --- --- ----------------------------------------------•-------------------(Owner and/or Contractor) By:----------------••----•-•---------------------------------- ------------ --•--------------------------------------(Title)---------------------------------------I----------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). CN FOR DE ARTMENT USE ONLY APPLICATION ACCEPTED BY---- -- ( ----------------------------- DATE... j �� " -2 REVIEWEDBY------------------------------------------ --------------------------- ---------------------------------------------- DATE. ------------------------- BUILDING PERMIT ISSUED--------------------------------------------------------------------- - ------------- DATE-•------------------ - Alterations and/or recommend'ations:------ i -- /r----- - _-- /__'fir_, _ _ C------------•-------------•------•- - - -----------------•- --------- --------------- ------------•-- ------------ ----------- ------------------------------•----------------- ---•------•------------------ -----•-------------- /' FINAL INSPECTION BY:, . .-- ------ ----- Date.-- _ _ _ J ti---- - -------------------------------- SAN JO QUIN LO AL HEALTH DISTRICT 130 South American Street 300 West ak Street 124 Sycamore Street*' 205 West 9th Street Stockton,California Lodi California Manteca,California Tracy,California E5 9 REVISED 8.59 2M 5-62 ATLAS