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6 14 APPFOR,$ANlTAT1QN 1 p IIITj� it No. {Complete in Duplicate) # moi` 't Application is hereby made to the San'Joaquin Local Health District for a per to construct and install }h a Issued5-----A1-,t3 This application is made in compliancewith Count manc No. 549, e wort; herein described. JOB ADDRESS DSL CATION._ -- - - ----- ----- ------------- Owner`s Ne -------------------- ------- ----• --- ------ Address--- } ---------- - Phone -------------------------- ----------------- --------- - ------------------------------------------------------ --- Contractor's Name.------- =--•-----•--•------•- --------------- f-- Phone ----------- Installation will serve:. Residence j partment !-louse ❑ Commercial ll i Number of living units umber_- ❑ Trailer Court [] Mot 1 ❑ Other, umber of bedrooms:l_--- Number of baths =-_-_ Lo size _ Water Supply: Public system Co munityfsysterri'❑ Frivafe ❑ DepflS}; Wafer Table .------- ft. t-i-_ Character of soil to a depth of 3 feet: S�Niew Gravel Sand Loam ❑ Y Clay Loam ❑ Clay ❑ Adobe �ardpan I] Previous Application Made: Yes ❑ N Construction: Yes Ee No a TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 2010 feet.) Se tic Tank. _ P Distance from nearest well --_-_-__.___-Disfiance from foundation_____.___.__.__--.Material--------------------------------------- -------- ❑ No. of compartments----------- ---- Size---•--•-------------------------Liquid depth---------------- CalaacitY -------- Disposal Field: Distance from nearest well__-------_--_- ❑ Number of lines--_-__�___------ 1 Distance from foundation___ ___.Distance to nearest loft line______._.__.- -- ------------Length of each line------------------- # Type or filter material_-__--------____-------Depth of filter material_ -.-- - . Width of trench._____-- 4 t Totallength---------------------------------------- Seepage Pit: Distance to nearest:well.-__"`__"` :-"`"" Distance from foundation____ __..._.Distance to nearest lot line----------------- Number of pits ------------------ Lining material---------------------- Size: Diameter__...------- f ) ----.--_.-Depth-------------------------------- Cesspool. Distance from nearest well-----------------Distance from foundation--- Lining material.__-_-.- ------ ❑ Size: Diameter-------- Depth ------ --- Liquid Capacity------ '1 _ gals Privy: Distance from neat est well__--_--_ f - ------- Distance from nearest building 16 Distance to nearesfolot line__________ ___ 4-------------______--__------ ---,-_ a -- _�_ Reino a in r p rin (describe):11 -------------------------------------- -------------- and/or --- -- --------------- -- -- ------- ------------------------------..... -= --------------------------------------------------- -� F€ •------------------•-------------------------I------•--•--I------------------------- ------•--------------------------------- -------------•------•------------------------------------ 1 hereby certify that I have prepared this application and that the work wi8 be done)in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) -• G� / - --------- -------- ----------------:------- ----- -- By:__ - {Owner and/or Contractor --- L-----•- ---:--�'I!�_"7'+--- ...! _ -}----�---(Tale)--------- ------------- (Plot pian, showing size of lot, ocation 5f system in-relation to wells, buildings, a#c„ can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY_ --__- -._-_-__ I_ _ , REVIEWED BY----------------------------------- - 'DATE- ---------- � ' ' ----------•-•---- ---- ------------ ------------ -- UILDING PERMIT ISSUED. «��.. -------------------- DATA ----------------------------------------------------------------------- A#orations and/or recommendations:-_-1____ DATE_._____- ----------------------------- --- -------------------- -1- -----•-----------•----------------------------------- ---------------------------1--•------•------------------••----•--- --•------•----•-------- .i-- ------------------ .____.___.__________._____._._.____.__...__._____.____ .__.._.-_--_---..-_--.---_--.-----__-----_-_-__--.__---. U --------------- ------------------------------'-_ -------------------------------------------------------*------------ FINAL INSPECTION BY:------- ------------------- . � ---------------------- ------ - Date------- --------- ______ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street Stockton, California 132 Sycamore Street 814 North "C" Street Lodi, California Manteca, Califorrtie Tracy, California ES-9-2M 10-52 Revised W-2100