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rrPermit No. APPLICATION FOR SAN .- j h TATION PERMIT q 1 (Complete in Duplicate) Date Issued _,L�---S;K_ Applica*ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. y This application is made in compliance with County Ordinance No. 549. l o�/S" 6' JOB ADDRESS AND LOCATION--- ---------------------------------- --------------------------------------------•-- -------------- ---- s - ----------- Phone------------------------------------ f, ��- - -------•-- ---------------------- ------------ • ' -- .---- --- --- _ ____Owners Name_____________ Address_... �� `�- r �7 -------------------------•--•--------------------------"-•---------------------------------•-----------• •----=--------- A. Phone__24/----------------------------------------------------- Contractor's Name-------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other C1 Number of living unitsi __ -" Number of bedrooms' Number of baths _/___ 'Lot size ____-�S�__-XI�+--•-------------------- _4' 'Number_ , Water Supply: Public system ( ommunity system ❑ "Private ❑ Depth to Water Table 9%rft. Character of soil to a depth of 3 feet: Sand ❑ Gravel F1 Sandy Loam ❑ Clay am E] Clay E] Adobe[c}—Hardpan10 ❑ Previous Application Made: Yes El No [�.}�New Construction, Yes [ No ' TYPE OF INSTALLATION AND SPECIFICATIONS: ;„4 'V I �. r No septic tank or cesspool ermitted if public sewer is available within 200'fee4':) . t i _ -Mater al-------------------�� -- ------- Septic Tank: Distance from nearest wel 1 rR, Distance from foundation_- "" �. �, ,. No. of corripartments €-r Size `` '`� Liquid depth. . Capacity `� Disposal Field: Distance from nearest well_ -.Distanc�-,from foundat'ion__�S-_--------Distance to nearest lot line._ S"-_�__. Number of lines` 1----------------- --- Length of each line_-----3lc--------------.Width of trench----- -y-------------k--------- Type of filter material_------ -„pepth of filter material-----��----.......Total length_- Q_.-----"-----•------------------ W _ mss- , N Seepage Distance to nearest well-- '_-_nDistance from .foundafion___�0_____.__.Distance to nearest lot ine_________________ Size- Depth `� LA Number of pits_-:__.�__________""Lining matenal_.J�__.��t/.�-�G-.maize: Diameter_____�� " Cesspool: Distance from nearest well----------------- from foundation----------- Lining material-----;---------------------- ”----- Size: Diameter = Depth -- -Liiquid Capacity------------------------°-9 ❑ -------------- -------------------------Distance from=nearest building , Privy: Distance from nearest well_.____ - "Distance to nearest lot line---------------------------------- ----------•------•--'--•--""""- --------------•-------------------------------- ? Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------°---------------------------- .... -_: ---- ---------------------------------- ., ----. ---- •----- ----•--•----------- ---------------- ----------••--------------------------------- 1 -------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health Distr'cf. , F ,C Contractor) (Sig -[Ow rand/or ' r a -(Title)- : , # r ------------------------ By:.................. .� /-------- [Plot plan, showing size of lot, location of s m in relation to wells, buildings, etc., can be placed an reverse side). FOR DEPARTMENT USE ONLY F ' ------ DATE APPLICATION ACCEPTED BY_____-_---,------ *Y%- - - REVIEWED BY--------------------------------------------- ---- ------------------------------------------------------ ---- DATE--------- - ---------- ------------•------------------- BUILDING PERMIT ISSUED - ------ DATE----------------------------------------------------------- -----•----------------------------- ------- - --------- Alterations and/or recommendations.---------------------------- ----------- --------•---- � -"-- --------••-•- - __ _ ---------- ------------= .c. - - ` =- ---- ----- -- -- ' Ik I --•---- --------- ------------------------------------ --------------------- --------------- FINAL INSPECTION BY:------ I 'yG:{_�/ - Date -!=-----"f -------------------------- -------- 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-9-2M ; Revised W-2100