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FOR OFFICE USE: P ------------- ---- - ----------------- APPLICATION FOR SALTATION PERMIT Permit No. - .- _-------- ------------------------------- ----------- ----------- (Complete in Duplicate) 7 Date Issued ..... ........�.._.. ----- _____------I----------------------- -------------- This Permit Expires 1 Year From Date Issued Application is hereby made to fhe San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliances with County Ordinance No. 549o(_ t arm 4- F-1(401-0 JOB ADDRESS AND L CATION---!�-------- � 1 `r Y,--------p"o�' � ------------------------ Owner's Name----------- G G��'/Lr -- �� -- ------ Phone------------------------------------ Address-------------------------------------------------------------------- -------~-rAddress-------------------------------------------------------------------- --•--------------------------------------------------------------`---------------------------------------•----------------------•--------- Contractor's Name----------------------- • --------- -•-----------------------------------------------------------•----------------------------•--- Phone-----------------------_-•------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ _ Number of living units: ___1.... Number of bedrooms ....'-Number of baths I--- Lot size -----.---4-0.k Z gQ ` �--1`r� r l R Water Supply: Public system ❑ Community system ❑ Private IK Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam K Clay ❑ Adobe ❑ Hardpan ❑ R Previous Application Made: (If yes,date. - I No ❑ New Construction: Yes ❑ No 0, FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: �v✓S� cq (No Septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well...-ut-'-_--v...Distance from foundation---/P----------Material......... ----------------------- No. of compartments----- .:?�77---------Size------ __.� :.;'..,_._Li uid dthe .......... . .. ---- Ca acit Dis osaI Field: Distance from nearest well.-N ....Distance from foundation_.... -----..Distance to nearest lot line.._. .. Number of lines_......._... '...............Length of each line...-___-- -.�.__ __ Width of trench.....---------- i Type of filter material _ ..-_-- - pth of filter material.-__.___..L�- Total length__.................-.6.v.-..._.. Seepage Pit: Distance to nearest well----------------------Distance from foundation..----------------- Distance to nearest lot line--------___------ ❑ Number of pits----------------------Lining material----- --------------- Size: Diameter-------------- -------Depth----------.---------------------- Cesspool: Distance from nearest well.................Distance from foundation____..--------------Lining material--__- .-...._-----.-----------. ❑ Size: Diameter---- --------- ----- ------------ ---Depth--------------------------------------- ------------Liquid Capacity_.------------------------gals. 1 Privy: Distance from nearest well-----.--_---------------------------------- _.-Distance from nearest building._-. ----------------------- -- -------- F1Distance to nearest lot line-- --- ---------- - -------------- ---- ----- ----------------------- --------------------------------- ---------------------------------- - Remodeling and/or repairing (describe)---------- - ------------------------- - ------------------------------------------------------ -------------------------------•------------------------ -------------------------•-----------------------•-------- -- --------------------------------------------•------------------------------------------------------------- ----------------------------------------------------- ------------------------------------------- ------------------------------•-----------------------------------------------•---------------------------------------------r---------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I -------------- 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, qnd rule an rggulations of the San Joaquin Local Health District. (Signed) -------------------------------------------------------------- --(Owner and/or Contractor) By:-------------------------------------------------------------------------------------- --- -----------------------------------------(Title)---------------- --------r------------ --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ` ---------------------------- DATE---------- ---- ---- REVIEWED BY----------------------------------------- ---- ---------- ----- v DATE-------------- --------- ---------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations:------------------- ------ ---- - ----------- -- ---------------------------------------------•- ------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- - ------------------------------------------ --------------------------------------------------------------------------I-----------------..----..--------------------------- FINAL INSPECTION BY: -- ----- Date---lw-- 5. -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r.PMEL