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APPLICATION FOR �'SANMATION PERMIT � V[Complete in Duplicate] •"��' Application is hereby made to the San Joaquin Local Health District for a permit ton" struct and install the work herein described. ,a This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--- ,2 0-_(,=-------- ----- - - ' Owner's Name-------- ---------- `� -----,--.-r-,-� -- ---- -- Phone-_-J" Address ---------------------- ,x-,--------------------------------------------------------------------------------------------------------- ------------------------------- Contractor's Name-------' -------------------- ------------------------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel K Other ❑ Number of living units: 6 Number of bedrooms ❑ Number of baths ❑ Lot size----------- _______________ Water Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe„k Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet,) Sept ic Tank:Tank: Distance from nearest-well__129�__Distance from foundation___4d__V--_-_--Material________ __________. No. of compartments---------�------------Capacity---2_��a_------Size____,��_�1_4-----_Liquid depth_-------�f0__��___. Cessspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______________________._______-______ ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_________________________________________. ❑ Distancejo nearest lot line------------------------------------------------ 4- r +4 Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Disposal Field: Distance from nearest w,�ll___/_� 'F'..Distance from foundation---�e'�-----Distance #o nearest lot line__��_______ Number of lines___________tf_____//��__-_.��____, Length of each line______`-'r—_O_�--------Width of trench________z�d_ ______________ ` Type of filter material__!'! __Depth of filter material--------1_if-___:___ Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------•-------------------------- ----- I -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-- ------------------------------- ------------------------------ ---------- --- - ----- --- -------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. F - Si ned t [ g )_________ __ r__ z. ____. "------ [Owner and/or Contractor By:------------------------------------------------------- -----------------�---------------------------------------------------(Title)---------------------------------------------------------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- __ _ _ __ DATE------------- � � - r---------- REVIEWEDBY---------------------------------------------- ------------ ---------------------------------------------- DATE----------------- ------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alteratiohs and/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_- --------------------------------------------------------------------------------------------------------------=--------------------------------------------------------------------------------------------------------------- 6 PERMIT No.7Q---4F-------- ISSUED----� 3 .-„ "�-------(Date) FINAL INSPECTION BY.,--- - y'r Dates'- ., -1 ------------------------- f _ SAN JOAQUIN LOCAL HEALTH DISTRICT i ` 130 South American Street ! Stockton, California ES-9-2M 9-50 W=1639 + t -