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APPLICATION FOR SAI ATION PERMIT v ,-- �` � Permit No. _ .. (Complete in Duplicate) Date issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and instl�a work1'7 herein described. This application.is made in compliance with County Ordinance No. 549. JOB ADDRESS ANDLOCATION-- -- p ---------- f , ` Owner's Name---•--�.(_1��--- �------ --��--R--��--' ��--•�------, --�� - - -- . ce-------------- Phone------------------------------------ Contractor's Name---------- ------------------------------- --------- ---------------------------------- - , - -------------------- ----------- Phone- �.- Installation will serve: Residence E] Apartment House ❑ Commercials" Trailer Court ❑ Motel ❑ Other ❑ Number of living units:,YQ_ Number of bedrooms -NQ_ Number of bathsLot size Z Water Supply: Public system ❑ Community system ❑ Private [KDepth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam Cla Loam Cla Y ❑ y ❑ y ❑ Adobe�` Hardpan ❑ Lj Previous Application Made: Yes ElNo r'--fNew Construction: Yes 1. No E] 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 foundation_1------------- ,Materiel_- No. of compartments-..-�� Size- �? Liquid depth- -rrF---- Capacity_ �d '�'rI/�-�1(1 /f �1) Disposal Field.: Distance from nearest well-._(2Q___--_Distance from foundation-- ----_-....Distance to nearest lot line_ - Number of linesidAt� ___-___Length of each line-- -__ -- Width of trench.-•L� _4.11 }a / �/ ------------------ Type of filter material-__ V�� Depth of filter material---- - ---------__-Total length--- s Seepa e Pit: Distance to nearest well_ r -----__-_-Distance from foundation--_ `�._._Distance to nearest lot line-_ _-_-- [� Number of pits- � -------Lining mate6aL_ �_��- -Size: Diameter'�_______________---Deptn_p �_-_ ----------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------- ------------------ ------------------- ___.____-_-_ _ ❑ Size: Diameter----- ------------- ----- - ------Depth-------- ----------- -------- ---------Liquid Capacity----------------------------ga Privy: Distance from nearest well----------------------------------------- -----_Distance from nearest building ❑ Distance to nearest lot line------------------------------------------------ Remodeling and/or repairing (describe):------ � -- -------- 1..� � /'r � a ----------- 4pp -----�' - l - r �-r ------ -- -1-----------•------------- -------------------------------------------------------------------------1� =v _::------------.-- ----- - ere y certify_ha#1-hZwe prepared thion and that the work will be done in accordance with San Joaquin County ordinances, Stateoawsl, and les and regulations�of the San /Joaquin Local Health District. (Signed) ----- -------------- --------�f. - ------`---- -- {Owner and%or Co tractor) BY� �'� �_ R (Title) L ------- -------------------- -( ) - ----�.-:�-- - "f (Plot plan, showing size of lot, location of system in relaVion to wells, buildings, etc., can be plaUd on reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ----------- --------- ---------------------- DATE---�-�"•----------------------------- ------------------ REVIEWED BY -- --- - --------------------------------- ----------------------------------------------- DATE------- - BUILDING PERMIT ISSUED------------------- ------------------- m ------------------------- -------------------------------- ............ ----------------------------- --------------- ------------------------------------------ -----------------------------------------------------------n- ----•--------- 1 FINAL INSPECTION BY:--- - ------------------ Date------------ -`------ SAN JOAQUIN LOCAL HEALTH DISTRICT 930 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 X-52 Revised W-2100