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�WPLICATION M. Px __�_�-�a -- .. P (Complete in Duplicate) y I �``� 74 - _37(_ Date Issued __- + Applica+ion is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. "3 This application is made in compliance with County Ordinance No 9. I JOB'ADDRESS AND L TI ------.. ...... - - Owner's Nam ---------- --- •--- -- -------------------------------------------- - - --------------------- Phone_ -tel Addre ---- - - --------- --- } -- ---------- ------------------------ ------------------ Contractors Name-- ------- ----- ---- ------------------------------ -------------------------------------------- Phone------------ ----- -------------- Installation will serve: Residence 'o Apar mein+ House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ti Number of living units: __e__ Number of bedrooms = _ Number of baths _0__ Lot size _. _` Water Supply: Public system Community system ❑ Private ❑ Depth to Water.Table_,��ft. Character of soil to a depth of 3 feet: Sand Gravel Sand Loam Clay Loam Clay Adobe Hardpan $ P ❑ ❑ Y ❑ Y ❑ Y ❑ p ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ ` a 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. of compartments----------- ------Liquid depth--------------------------Capacity----N--------------- Disposal Field: Distance from nearest well.................Distance from foundation------.---------� Distance to nearest lot line-------- ! ❑ _ Number of lines-----------------------------------Length of each line------------------------------Width of trench--------- ------------------------ Type of fitter material-------------------------Depth of filter material--------:--------------Total length_---------___-_-___-______________------- I Seepage Pit: Distance to nearest well_--------------------Distance from foundation--------------------Distance to nearest lot line--------------- ._. ❑ Number of pits--------- ------------Lining material-----------------------Size: Diameter-------------------------De ------ --------------- ____ � Cesspool: Distance from nearest well-.xt•. ---_-_Distance from fo undafion-_/009--r Lining materi I___ , '- f Size: Diameter -------------------------- Depth - Liquid Capaci � MAL - Privy: Distance,from nearest well------------------------------------------------Distance from nearest building_-------------------------•---------------. ❑ Distance to nearest lot line-------- --• ------- ---• - --------- ------- -----------------•-- - ------------- ------ I `. Remodeling and/or'repairing (describe -- -- ---- _ _ _•------------ ------------ ------ ----------------------- ----------- - --- - -- -----------....---------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------.--------------------------------------------------------------------------•------------------------------------------ j.�� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin CountyrV'11, ordinancEng e law and rules d regulations of the San Joaquin Local Health District. (, (Sined --------------------------- --- ----- -------------- --•---------- 9 } f---- -- -------- -(Ow d/or ContractorB -------- . l'..... �'-�- ------•--------------------------------------------------------- (rile {(Plot plasize of lot, I cation of system in relation to wells, buildings, etc., can be placed on re erse si FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- - DATE------ REVIEWED BY----------- = ----------------- RATE--- -- ----- - BUILDING PERMIT ISSUED_:_...----------------------`------- --------------- .11DATE------------- -_-- t Alterations and/or recommendstions: ' -------------------------------------------------- ----- --------- j - --------------------- -------•---•-----------------------------•----••-----------•-•---------------------------------------------- --------------------- --- ----------------------------------------------------------- --------------------------------------- FINAL INSPECTION BY:.`--- ----------------------------------------------------- Date7..` 5 ' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street `s 300 West Oak Street 132 Syeamoro Street 814 North "C" Straef Stockton, California M Lodi, California Manteca, California Tracy, California - E."-.---9 145446 ATWOgD