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r �l-1-ILt: 1 -------- ----f 7-7 - ------- -------- ----------------- APPLICATION FOW-SAMTATION PERMIT Permit No. - ----- -- ----- --- ----- -------- --------- "-- (Complete in Duplicate) ` l This Permit Ex ires i Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and.install the work her e(i described. This application is made in compliaiwith County Ordinance No. 549. � �,5'" • • JOB ADDRESS D LOCATION_Name � _� � 3• • �` '� - ' #'- Owner's N ___ Address ... ` v�a1 -------- Phone---------------------------- ----------------------------------------•------------------------ Contractor's Name__ _ ----------------------- Phone------ --•----------••-----•------- I Installation will serve: Residence Apartmenf House ❑ Commercial ❑ .Trailer Court : E] Motel ❑ ,Other E]Number of living units: -1---- Number of bedrooms.._ Number of baths __ ____ Lot size Water Supply: Public system ❑ Community system ❑ Private P-16,pth to Water Table __�_?"ft. Character of soil to a depth of 3 feet: Sand I] Grav Iel E] Sandy Loam E] Clay Loam [:] Clsy [:1 Adobe�ardpan F]Previous Application Made: (If yes,date l No ❑ New Construction: YesNo TYPE OF INSTALLATION AND SPECIFICATIONS: ❑ E] FHA/VA: Yes [:1 No [� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation__________________Material ________________________________ ❑ No. of compartments--------------------"-_'Size-----•------------ "---••-------Liquid depth------------------------- CapacitY-•--------------------• Dispos Field: Distance from nearest well----.5t__ Vstance from foundation---e�-'-- Distance to nearest lot line___ -r..--_- Number of lines-r_____- - Len to of each line_--._/�Q_:------ -_ti--.Width of trench----' ---------------- ------ --------- -- # 9 Type of filter material----- -;-i •,_-------Depth'o�f".filter material----- --'. --Tofal length'---1__4r__o------------------------ Seepage Pit: Distance to nearest well_ ---------- ____.__.Distance,from foundation-'------------------ to nearest lot line._._._____.______ Number of pits-------- Lining mater.i.al-- -- --- ---------Size. Diameter._ --------- ---------Depth-------------- ------------------- Distance Cesspool: Distance from nearest welofu El Size: Diameter " ' m odation_______________.__ fining material_ __---------------------------------- o--------------------Depth------------- l � uid Ca Capacity 9as.Pnvy: Distance from nelarest we ______. _ � f - ----------------- --- --------------- __yam _ Distance F from nearest building---------- Distance to nearest.•lot_l.ine =-- "__ ------------------------------- Remodeling and/or repairing (describe)___________________ _ --- -------- -------------------------------------- -------V ---------- -------- ------- •----- ---- ---- -- •--- ------------------- --------- . -------- -----•---------- ---------------------------------------- -------------- ------------------------------------------------------------ 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 laws, and rules and'regulations of the San Joaquin Local Health District. (Signed)---------- - ------- 7/----- BY:---- QIrezia r Contractd/o or)-------------------------------------------(Tifle)------- ----------- ---------- --------- --- (Plot plan, showing size of lot, locatio, of systemion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 7 ! �� REVIEWED $Y---- ------------- ------------------- ---------------------------------------- DATE.---- - ------------------------------------- --------- - -- --------- ---------- - ---------- DATE----------------------------------- BUILDING PERMIT fSSUED-----------------�-- _--: --------------------------------------------------------------------------- DATE------------------ -....................... - ------- " " -----"" ------" ------•--- •-- Alterations and/or recommendations:._I_______.__..__--.--_ f --------- ------- --------------- ----------------------------------- ------ ----------------------- "----- ______________"-_______----_______- ---------------- FINAL INSPECTION BY:. - - - Date--- 9"1�_Z b -------------------------- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi, California Manteca,California Tracy,California F.F.0 D.