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+�vR vrr •. 1) -------- APPLICATION Ie0R SANITATION PERMIT Permit No. ._� -3 , r//-------- ------------ --- -�/ ��% _ (Complete in Duplicate) y ------------------------ --- ------ -- --- This Permit Expires 1 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 herein described. This application is made in compliance with County Ordinance No. 549, JOB ADDRESS AND LOCATION .... _ -gin------ Owner's Name_____ _ -------- - --- ---------------- ----------------- -- Phone-_--------------- Addres - � tt— ------ •------------------------- ------------•----•----------••--------••----- Contractor's Name---------- - - -- ---------------------------------------------------------------------------------------------- Phone Installation will serve: Residence V�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __./_ Number of bedrooms -./--- Number of baths _/--- Lot size Water Supply: Public system Community system ❑ Private [] Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe -lardpan ❑ Previous Application Made: (If yes,date_ ------- _____ ) No ® New Construction: Yes ❑ No [l}'~HA/VA: Yes ❑ No 9 r_ 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---________--_ ----.Material.-----------------------------------------� ----.. No.lof,compartments----- ---- ---- ----------Size-----•------. ----- ----Liquid dep th--------- ---- -------- Capacity-- Disposal Field: Distance from nearest well________________Distance from foundation___� 51_-_r .Distance to nearest lot line___ 1r Number of lines----l______.__ _ ength of each line______ __ - r - ��------� Width of trench--'�-- ------•---- ---------- Type of filter material_ � e t t e-T - if p h of filter matenal___/s --------Total length_____ -------------------------- w _--.-----__ - ------------ Seepac�e Pit: Distance to nearest 'weiL__�-^~�------._-Distance from foundaticn__ _.Distance to nearest lot line_. �.x.- �� Number of pits---/----------- --Lining material_ � i.5ize: Diameter_---�_� '_-__Depth Cesspool: Distance from.nearest well_________________Distance from foundation----- ----------- - Lining material----__-.-.- -__-- _ -------- 0 Distance Diameter-e from,nearest - Depth - - - �-Liquid Capacity_--------------------------gals. Priv well------------------------------------------ --- --Distance from nearest buildin9 ----------------- ❑ Distance to nearest lot line______ - ------- _- --------------------------------------- ------------- Remodeling and/or repairing (describe):_._-__-_-.-_ .-........... jrlr --------- ----------------------------------------------- -- ---------------------------- -------- ------- f ----- ----------------------------------------------*------ ---- -------------------- ----- ----•---------------•-----------------•----- _ 1 --------------- - --------------------•-------------- ------------------------ 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) / / ----------------- Contractor) By:-------------------- -- -------------------- �-' Title (Plot plan, showing size of lot, location of system in r ion�fo wells, buildings, etc., can be placed on reverse' side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ _. ---- ------------ - ------- ------ ------------- - - ------ -- - BATE--------- �✓'7-•---- - --------- �---- REVIEWEDBY--------------- ------------- -------- ----------------------------.----------------------------------------- DATE---•---- BUILDING PERMIT ISSUED---------------- --------------------------------------------- - ------ DATE Alter ion and/or recommendati s:_-._ ___________________________ ---------- _ ---------------------------------------- - - - re -.-� ` _. ,., � * --- - ��--tea - --------- - -U -- FINAL INSPECTION $Y:-. --------------- ------------------ - Date------- --` � =7 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E,t1a:elton AvQ. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy, California F.P.C L3.