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1'�APP�I . CATION FOR SA >J� NITATION PERMIT Permit -f" �I L (Complete in Duplicate) 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- XA! LKe�---------- Owner's Name Add ress_---=---------------- es` „. --------------------- ----- - Phone---- F-)'�-9-L16 'k - ow f - - - ----------------------------••--------•------•------• -------------------------•-----------------•---------------•----------------- Contractor's Name --- ------------------- = ---------------------- Phone ------ Installaf n will server Residence Apartme t-House ❑ Commercial ❑ Trailer Court n ❑ Motel ❑ Other ❑ Number of living units: ---- ---- Number of bedrooms _ Number of baths A----- Lot size _---- - _ }_ ---_ - Water Supply: Public•4s. stem \ /Y �--�'`-Y----------------------- PPY� y�� ❑ ommur tosys#em ❑ Private''X Depth to Wafer Table __ d- Character of soil +o a depth of 3 feet: Sand°'�. "� ft. '! ❑ Gravel ❑ Sandy Loar`n OClay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes j�N.o�' x ❑F New Construction: Yes V No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS; (No septic tank or cesspool permitted if-public sewer his vailable within 200 feet.) Septic Tank: t Mrs,.�Distance from nearest well -----Sfs _D nce,from foundation-_----J�_---__-- No. of compartrhents------ y,r - ,,�`, Size's • - X_ Liquid depth---- ----y `SCa acit - �ff Disposal Field- ' C,,Dis#ance,from nearest well-__._50-___--Dis ante from foundation-_---__ "gyp y Numbe� of lines- ------ _-- " ----...--Distance to nearest..0 line_,-._5'-�--- Length o, each line XQ Width of trench------� f � Type or filter material- -_ - V6GL( ' p - -- -------------- thof filter material----- length----------- Seepage. 3 Pit: ! Distance to neares well----------------------Distance from foundation-- . ❑ Number of Pits.A----------------- ----- Distance to nearest lot line-.-------- ------ -------Lining material�--------�----- -_----Size: Diameter----- --- --- -- Cess ool: --.----Depth------ ------------------ p Distance from nearest well-------------- , ► Distance.from foundation--------------------Lining ma#erial--_____------------__--_------------ • ❑ Size: Diameter---'t•------ ----------------- ----Depth�----t------ t ---------------=--- ------------------Liquid Capacity----------------------------gals. Privy:... Distance from nearest well---------------------------------------- - `- Distance from nearest building Distance to nearest-lotil;ner—.,�.-w-.�.,..,�-..-,�--' -• 9 t ------------------ --------------------- and/or repairing (describe)--------------- ---------------- [� ----------1; --------- - ------- -------------------------------------- ---__---_-._- -•___.--- _.------_ -----•------------------------------------------•--------------------- I hereby certify that I have prepeFed this application and-that the work will be done in accordance with San Joaquin County ordinances, Slate laws, and rules nd regulations of the an Joaquin Local Health District. (Signed)--_- gY:• --------•--------'- -------•----•-----• ------------------------------------------------------r- ------------------ --(Owner and/or Contractor) --•---� -------- ----•--- •--- ------------------------------------------•-------- --- ----- -------------------------------------- - -(Title)--------- ------------------ -------- ------ -- _____ _ _(Plot plan, showing size of lot, locafion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_7----------------------------_ REVfEWED, BY ' ( DATE -------------------- --------- ---------------------- ' 7' BUILDING PERMIT ISSUED------ = -€ DATE ___ ____ - -. DATE - Alterations and/or,recommendaticns:___j ________ _ ---------------------------------•------------------•----•--------------•----•------------------------------------------ -------•- ----. 9' �J_s-3.=--nCep.._= -------------------- " '��r,� - -------------- �' �� K------- ; --------------- I r�� `"------------ -------------------- -- FINAL INSPECTION BY:.--_--- --•----= --- • -------- ------ Date-- ---- -- ------ d - ------------ t SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street ' 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California� Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100