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vrs, vrrll,c Ui -------- --- -- APPLICATIQN FOR�SANfTATfON PERMIT Permit No. (Complete in Duplicate) --- ---- - ------------ lT i, Permit Ex ires 1 Year Froin Date Issued f - � Application is hereby made to the Sara Joaquin Local'Health,District-for a permit to construct and install the work herein described. This application is made in compliance with County Ordinahce;_N 54q. , ' 9 JOB ADDRESS AND LOCATION_- 02- y� --- --- Owner's Name------• �- -- r./ 'L - 17 -••------••--"------------•--• --••-----•---------- - - -•---- •- -• --- Phone._-... Address-- y r a---------------- Contractor's Name.-_- •---........-•---••---•--------------••----••-- Y _ ----------�-. --jam- - ----------•-------- -------------- --------•-------_-------- Phone----------------------------------- Installation will serve: „Residence M Apartment House❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: .- Number of bed?ooms�-�-.�Number;of baths _-/.-- Lot:size __-_ P Water Supply: Publics stem r GPY� y ❑ Community system ❑ Private Deep th_to ,V�-later Table /Q-, ft. Character of soil to a depth of 3 feet: Sand ( ravel,❑� Sandy Loam ❑ Clay Loam [3Clay El Adobe Hardpan ❑ Previous Application Made: (if yes,date------------ j No New"ConstFuct/ YesA No TYPE OF INSTALLATION AND SPECIFICATIONS: �. ❑ FHA/VA: Yes.❑ No 19 __.- (No sepfic tank or cesspool permitted if pu lic•sewer is available *ithin-200 feet.) Septic Tank: Distance from nearest well_ . --- ----Distance from foundation:,� 1- PO No. of compartments _--, . / Material" -- p Siie - -- Liquid depth �. Disposal Field: Distance from nearest well_"�-- - I Capacity--.r�C1' W �___--Distance from foundation-� _, --__-Distance to nearest lot line._-_ -- Number of lines.-_ ---_--._-' -,� '(w) Type of filter maferia- e th of filter material_ --'Width of trench--_ --"---" ,-- - engfh of each line________ _____ ___ - - p ____________ p 9 Distance to nearest well----__------_---_-_Distance from foundation--� Total length----___. - See a e Pdt:_ .. •---•------------•-- {, rSize: Diamete Drstance to nearest lot line_-.--- ---------------- _- ❑ Number of p#s_.-- Lining material ---------------------Distance from nearest well-----__-_--- Distance from foundation.`................ Lining mateDapth-"-- tr I . Size:^Diameter � s Deptti "°�'- -- --� L -• 1.�� F.,. clu P Y�'•�----------------------gals. ... g Privy: Distance from nearest well-_-.--------•--------------------•- � a C� acct , --------------- Distance from nearest buildin ❑ Distance to nearest lot line----- ------------------ - -------------------- Remodeling and/or repairing (describe):- _ -------------••-- -------•--------•----------------------•--------------•- I --. .__•-- ' ._-'- ------------I --—.___.-------------------------•-__----___.--_•--.___-..--_••--------.__--.__•----_._-__-_----.-_••_-----_-_---..----.--_--------_-- - _ -_-•-------------------.-..--.--__._-_-.---__-_--^`-------------------------- I hereby certify that I have prepared fats=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)-)(% BY:------------- ----------------------------- ---------------------------------- , X - --------------- - --- .(Owner and/or Contractor •--------:-------------- _ _ {Title (Plot plan, showing size of lot, location of system,in relation to wells; buildings, etc., can be placed on reverse side). J FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY3- ---------------------------------------- --------------- DATE-- 4------ -- -- ------- REVIEWED BY _ -•------ ---- ------------- BUILDING PERMIT ISSUED -' ,DATE----------------- ---------- -----------•---- ---.''DATE.- Alterations and/or recommendations:----""--"--_.- i. -----------_".............."----. ------------------------------------------------I --- ------------------------------•----------------------•---•---------------- - 1 ---- ----- ----- ------- i FINAL fNSP , 6- Date- c �� - -----L— "A -- 4� 1 1�+ - ''� v fit - SAN JOAQUIN LOCAL HEALTH DISTRICT ha%South American Street 3R!West opk Street; " _ ] 124 Sycamore Street Stockton,California �.c1l Califor205 West 4th Streetrila t Manteca,California Tracy,California E9_9 gEVl6 ED e•$9 r^CO.2M 6.6D �{4,• t