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---- ------VC R UVVICE USE --------------- ------ -------------------------------------- APPLICATION FOR SAII7ATION PERMIT Permit No. /___... --- ------------------------------------------------ (Complete in Duplicab) ----- ------------------------------- ,issued Date Issued - --------------- This Permit Expires 1 Year From Date Application is hereby made to the San Joaquin Local Health Pi5frict for a permit to construct and install the work herein described. This application is made in cou li� ith JOB ADDRESS AND LOCATIO�N_./ �/V t/�J ccc�� l�ftL v ` , / ` Owner's Name , ^{_-------'-� - -- -------- -- --- ------------- Phone----••----------------- Address13 � �------------------------ -----•--•------•--------------------------------------------------------- ------------- Contractor's Name------- �".- -----------------------------------------------------------------------------------------..._..-.-.------------- Phone----------------------------------- Installation will serve: Residence J)� Apartment House ❑ Commercial ❑ Trailer Court .❑ 'Motel ?111�r ❑ Number of living units: ____. Number of bedrooms _3--- Number of baths _ _._ Lo size __//. " d _____________________ Water Supply: Public system ❑ Community system ❑ Private ¢] Depth to Water Ta __.�ft �� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam.•] Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: {If yes,date--------------------1 No ® New Construction: Yes-] No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: O(� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--r O---t----Distance fromf ndation------?�O-----Material M No. of compartments--------9--------------Size ---1--------------I ---.---Liquid depfh.-.4V---------- Capacity-JA Field: Distance from nearest well_t 70. _f......Distance from foundation__t0_1--------Distance to nearest lot line__ _._____ 1E, Number of lines-----�-rr---- - - - -- ------Length of each'line_� q_'_�[_:'--1 --'_7_.0-_.Width of trench.---3_fa ,_- ------ O Type of filter material +', -----Depth of filter material___- -----------Total length_ _1A9_!_1______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to near s lot line_____-________--_ S ❑ Number of pits----------------------Lining material---------------"------Size: Diameter---------------_--.----Depth--------------------------------- 1, Cesspool: Distance from nearest well-----------------Distance from foundation....---------_--.__.Cining�material,_----__-_-____-_______-_- S1. I ❑ Size: Diameter---- ---------------------------------Dept h----------------------------------------------------Liquid Capacity- -------------------------gal Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_________--_----___-_______________-__-_. [❑ Distance fo nearest lot line------- Remodeling and/or repairing (describe)----------------------------------------------------------------------------------------------- ------------------------------------------------------- ------------------------------------------------------------------------------------ -------------------------------------•--------------•--------------------------------------..-------------------------------------•------------------------------------------------- ------------------------------------ ----- . ------------------------------------ ----------------- -------------------------------------------------------------------------------------•-------------------------------------------------------------------------------- I hereby ce i that_1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances;�Sta I ws, and rules egulations of the San Jo quin Local Health District. (Signed)-- ----- -- ----- ---- ---- - ---- -- ---------------------------------------- Owner and/or Contractor I By: --- ------------- ------------------------------------------------(Title) (Pl'ot_plan, showing size of lot, location of system.-in-fe"ation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------------------------ DA E-• ---- ------ ------------------------ REVIEWEDBY. ----------------------- --------------------•--- ------ ------------------- ------- -------------------------------------- DA -------------=----•--------- ---- BUILDING PERMIT ISSUED------------------------------------------ --------------------------------------------------------- DATE----- --------------------- Alterations and/or recommendations:---------------- --------------------------------------------------------------------------------------------•------------------------------------------------ --------'------ --------------- ------------------------------------------------------- -------------------------------------------•---•------------------------------------------------------------------------------------------------------- FINAL INSPECTION - ---------- Date-_1'�.4 -le.!- -- -• - ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT t: 1601 E.Ha=ellon Ave. 300 West Oak feet 124 Sycamore Street 205 west 9th Street Stockton,California Lodi,California' °' Manteca,California Tracy,California ES 9 REVISED 8-S9 3M 3•'63 F.F.00.