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FOR OFFICE USE: ............ ----- - ------------------ APPLICATION FOR'SATfITATION PERMIT Permit No. . ...... � (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued ..Application is 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 com li rice with County Ordinance No. 549. 0203—Z 021{ S � JOB ADDRESS AND CAT-0'Ofl .L�Ct,�,r(e!„�--- -.. ..:.---{-�-C.4s� _S�_ ��.d1'ee.!.'.. --0----L....----•-•-------_.... Owner's Name..__ s✓..././../2✓*!Vo ------------- --------- - - - ..... ............... Phone............. -rte f---- fir^ -................. --- Address -- .... -- ---------------------------------------------- Contractor's Name..------ . . .................------------.... ._..._.........------........... ............//� . . Phone................................... Installation will serve: Residence Apartment House ❑^�Commercial E] Trailer Court ❑ Mot 1 ❑ Other E] ' Number of living �units: ... ... Number of bedrooms .9-.2-Number of baths sL . Lot size Water Supply: Public system ❑ Community system [I Private to Water Table�r�F.. tt- Character of soil to a depth of 3 feet: Sand F] Gravel ❑ San `Loam❑ Clay Loam❑ Clay ❑, Adobe Uv<rdpan ' 9 f � s Previous Application Made: Ilf yes,date....................) No , New Construction: Yes� 1Vo ❑ FHA/VA: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ((�4 �� - (No septic tank or cesspool permitted if public sewer is available tithin 200 feet.) p p Septic Distance from nearest well.1Q.Q.�_.Distance from foundation....// .....Mat r��_-_a.41__6P1 ce....... 21, No. of compartments.......="O.�----.__Size.. .�!l. .Liquid depth____--4T r, Capacity.-.tQ �o Disposal a d: Distance from nearest we1L� �-.Distance from fouy0at`pn../�_-- ._Distance to nearest lot 1��.-........._. Number of lines....... Length of each -----Width of ___...._-.._ X r !!..._Total len dh_-. fP_�. W Type of filter material._ �yr.� epth of filter material._! ........ g /..... . ........._.......... / • / / N Seepag Distance to neares well_JA.4__---_-Distance m f oundat' n____/4?!.._..Distanceio nearest lot 1 ..I../.fh UK Number of pits----.-......._Lining material.. fRt<P..ZL;;_ Diameter_.. ��..:• Depthc 1,_r_ 4 :.r.... ti"� Cesspool: Distance from nearest well.................Distance from foundation.................._Lining material.................................... ❑ Size: Diameter---------------...._..................Depth....................................................Liquid Capacity............................gals. ._: Privy: Distance from nearest well-----...._._----------........................Distance from nearest building---........................... ........... ❑ Distance to nearest lot .., lin..e...........D....G....✓.........._..�.`5------- -----„-�-l--�—..l...h........._._._..J.......-....(.�.^^_._..-.....-.-.•_....... ................................................ ..C'.L.. .............. Oi Remodeling and/or repairing (describe):.._...- . , ma. ............................... .............__........`-.................................................................................. ----- -� - ------------------A- - wf �t hereby certify that 1 have prepared'this'appBcation-and-Aartfieworkwill-bd-d'one'iR accordace w' San Joaquin County .°!.�'inences, $tate and rules an r ulations of the San Joaquin Local Health District. 57 (Signed)............. Q (0`.. -. ` .............. - -- - ......... ._r.... ..... ....(Owner and/or Contractor) By:-- .._.............. . C X9.1. . _ ....................... Title).... : .. ... , '(Plot plan, showing size o o location of system in relationo'wells, buildings, etc., can(Title) be placed on reverse side). J FOR DEPARTMENT USE ONLY 0 i APPLICATION ACCEPTED BY..C.� .L�..............s............... - DATE.. ....... f.......................... REVIEWEDBY........ ------......................i. ................ -- - - LATE...__...................................................... ' BUILDINGPERMIT ISSUED....-----.... ---..._.... -.......................----------........-------------- DATE.--- .......-....................................------ AAera+ions and/or recommendations:..........................................................--- -----.......--..................--.................................................... ............................---------------------------...................................................................................... - ...........------ ...---...................----......._.... -------------- ....... ................................................................................. .....---- .....................................------......... - ....._------------------------- - -• ..........._....... .- ........- ..... .........----- ----..._....... . - .........-------........................ ---------- \FFIN L INSPECTION BYL�`r — .. --------- Date..e%..- Y.44......... . _........ __ , V SAN JOAQUIN LOCAL HEALTH DISTRICT+ ' V� 1 I n i, ' y 1601 E Xardron Ave. 700 West Oak Street 144 Symmers A col 705 Wezl 91h Sirect Srodton, cel ifernie Lodi, California ManBca,California Tracy,California F.P.CO.