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APPLICATION FOR SANK ' ATfON PERMIT Permit No. __f�0__�_U_. 1 .3,0 (Complete in Duplicated 71 Vh 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 LOCAT ON .5 / _� -a - ---------------------------------------------------------------- i Owner's Name----------- Address -l7 _ --------------- PhoneA0. i'1"�?._ ----- ----------- Contractor's Name________ - �._ T ---------- ----------------------- ------------------- - ---------------- ---------- Phone--Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _I/__ Number of bedrooms __/_ Number of baths ___r_ Lot size ____ 1 1 ` ---- Water Supply: Public system?9� _Commun'ity system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E] Adobe Hardpan ❑ Previous Application Made: Yes ❑� No-,R� YNew Construction: Yes ❑ No A/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 'FH (No septic tank ar'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well _Distance from fcundaf on____ -_____Material_.__ ------------------- 9- 411 ' ----- ---- No. of com artments__ ----------- ----- Disposal �-- ------------- Size_ � �-�__-------Liquid depth__.5�� ----- -Ca aci Disposal Field: Distance from near st well-t4fXU--.-Distance from foundation_A49�____ isfance to nearest lot line----+c�__, Number of lines . of each line_ 49-r '�.4r-_7Width of trench__ --"`� 92_"_-- Type of filter mate6al_________________________Depth of filter material-----------____ ____Total length________________________-___ ------------- Seepage Pit: Distance to nearest well------________________Distance from foundation___________________.Distance to nearest lot line-------------- r❑ Number of pits----------------------Lining material--------------------- Size: Diameter--- •--------- -------.Depth----- -------------------------- Cesspool: Distance from nearest well Diameter __Distance from foundation_------------------ _ material_____ __ ___--___-__--___--___. {"�\ ri ❑ �:.r- Distance r romr nea est well � Depth-----------------------------------------------------. -. Liquid Capacity -gals. Privy: r I. � _______________Distance from nearest building_________--_____ Distance to nearest lot line_____________________- IF - El t, ---------------------------------e----------------- -- - ---- -------- ------------- ---------------------------- r - Remodeling and repairing (describeJ:_ __ --•- ,�-------.1( ----- ------------•--------- v -------------------------------- -------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereb certify that I have prepar d this application and that the work will be done in accordance with San Joaquin County ordinance Ste aws, and rules and r ulations of the San Joaquin Local Health District. (Signed)------------ r_ _�_ O ------------- ------ ------- ---. _ .,. _- and/or Contract her o or) By:----------------------------------•-- `V-------- ---------------------------------(Title)--- � (Plot plan, showing size of lot, I ation of system in rel ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY--------------------- _ = DATE-- --------- REVIEWED BY-------------=----------•----- -�-- -- ----- -i - ------ ----- ------------------------------------------------------------------------- DATE - --- -- BiJILDING PERMIT 155UED �-------------------- ------------- ------------------------- ---- ----- DATE_ --------- --------------------- -------------------------- Alterations and/or recommendations:______.__._______-______- -------------------------- -------------- - ---------------------------- ------------------------- - ------------------------------------ ---------------------------------- ---------- _"_-- ---------------------------------"--- 1 -------------------------•---------------- ------------------------------------------------------------ -- - ------------------------------------ ---------------------------- FINAL INSPECTION BY------------- ___ Date_._ ----------------- `1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21x1 , ffevised 1.57 F.P,CO. ) I