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1 VI+t1 APPLICATION FOR S �ATION�PERMIT Permit No. I ; {Compin -if e lete - I � �• ) 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 hhlCounty Ordinance No. 549. JOB ADDRESS AND OCATION _. " * - -----------------------------------•------------...-------------------------------- 'h Y Phone----------------------------------- Owner's Name--------- -' --------------- . �`� . Address---------------•-�f -+ - ----------------------------------------------------------------------------------------------------------------------------- --- Contractor's Name------- -----�"�''1- "---------------- -------------------------------------------------------------------------------- Phone---------------------------------- Installation will serve- Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: . Number of bedrooms -__/ Number of baths . .._- Lot size -_sS:7)P�x_2(A..77.............------.._ Water Supply: Public system J Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑, Sandy Loam ❑ Clay Loam 0 Clay �' Adobe E] Hardpan - Previous Application Made: Yes ❑ No X New Construction: Yes ❑ No j TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` Septic .nasi •I�" Distance from nearest well-----------------Distance from foundation--------------------Material-------------------------------------------------- ❑ � No. of compartments--------------------------Size--------------------------------Liquid depth -------------------------Capacity------ ------ _.-V ----- Disposal Field: Distance from nearest well--�f"�Distance from foundation--o- � ----------Distance to nearest lot line=-.1�__..._...- Length of each line--..__�.4-_�__1r�...._.Width of trench... _.__�- Number of lines--------- ------------------------- ` --------------------- Type of filter mate ria l__-----.-Depth of filter materia!----If------...__.Total length__..__P4---------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------_Distance to nearest lot line__..........- - 1 ❑ Number-of pits----------------------Lining mai-erial-----------------------Size: Diameter-----------------------Depth--------------------------------- v Cesspool: Distance from nearest well._.._..._...-...Distance from foundation_______________....Lining material--_-___.__ ------______---__._.,_... pSize: Diameter------------------ -------------------Depth--------.-------------------------------------------Liquid Capacity. -------------- ---;;- 9als... ._---- ---Distance from nearest building Privy: �]istarce from nearest well - -....-... ..-____ _. g----------------------------------------- ❑ Distance to nearest lot lire-- --------------------------------------------------------------- -------------------------------------------------------------------------- Remodelingand/or repairing (describe)-----------------------------------------------------------------------------------------------------------------------------------------------•----------- x t ............................................................................................................------_..-.....__..-...___-_---..._...._...____-_--..----.-____..._._..-_-..__.._._._-_____-________:._-._...- .............................................................................................................................................................................................................................. I lication and that the work will be done in accordance with San Joaquin-County I hereby certify that I have prepared this app ordinances, St I ws, a l ia�nd regulations of the San Joaquin Local Health District. {Signed) ----------- --------------------------------------------- (Owner and/or Contractor) By:----------- ----------------------------------------------------------------------------------------------(Title)------------------------------------------------------------:, (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ------ --------- ------ --------------------------------------------------- DATE---REVIEWED BY -------------- - ------- DATE ' BUILDING PERMIT ISSUED------------- - - ------------------------------------------ DATE Alterationsand/or recommendations:--, ----------- --------- ------------ -------------------------------------------------------------------------------------------------------------------- ---------------------------- ..- r-----------------------------------------------------------------------------_ e---- - ---------------------------- --- t'�.'- = = ------_------------------ -------------- --------------------- - --------- ------ --- _ .^'Glee.I.__ Date------------ l - --------- ' : FINAL INSPECTION BY-------------------------------------------------------- - --------------- 4 SAN JOAQUIN'LOCAL HEALTH DISTRICT 130 South American Street - 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M 5-51 Revised W-2100 � �1 w }