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FUROFFICE USE: ---------- ------w-------- ------ - -- ------ ---------------------------------- --------- APPLICATION FOR: SAMTATION PERMIT Permit No. -------------------------- - --- - (Complete-in Duplicate ---- - ------------- ._ .---.. -- This Permit Expires 1 Year From Date Issued Date Issued --_-/5:�� 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 ' -�--------- "` �✓G�� J�- ✓�' Owner's Name �/, '"c 'twi��- 1�'' = -- ------------- Phone--------------- ----•-•-------•---- Address...........eb51"a i-0-------------------------------------------/------ - - .� --------- ------ ------- -----------------------------------------------Contractor's Name----------- - �� Phone------------•--•-------••--------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ' - Number of bedrooms Number of baths 4 Lot size 1,,.--ef/ �_'---------------------- -- -- Water Supply: Public system ❑ Community system ❑ Private g?"IDepth to Water Table�'�' eft Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date---------------.... ) No A' New Construction: Yes 2-Tlo ❑ FHA/VA: Yes ❑ No f;-- TYPE OF INSTALLATION AND SPECIFICATIONS: R� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) N Septic Tank: Distance from nearest w�ell. --Distance from foupdationZAW---------Ma�rial�.�G� ................. Nt No. of cam artments_ aa - ` e�l� f��Liquid depth-r. -r-.- ..__-_ Capacity/_, ---- o� p b -..Siz , .�W--..-.Distance to nearest lo{ Disposal Field: Distance from nearest well-7A0....Distance from foundation q Number of lines--- •_-__.�.-. --___ Length of each line_ �`:jllapyf.-.Width of trench-. 9-------------------------- Type of filter material Depth of filter material--- --_---.Total length--_-'-s0_4 ------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line----------------- El Number of pits--- ------------------Lining material---------------------- Size: Diameter-----------------------Depth------------.------------_------- CesspooL• Distance from nearest well ------- -------Distance from foundation-__----------- ..Lining material------.-__------------.-----_------- ❑ Size: Diameter. .- .-------- ----- ------- -------Depth----------------------------------- - -- - -----.Liquid Capacity----------------------------gals. Privy: Distance from nearest well.......................... ......................Dl stance from nearest building.-----._-------.---___-__------_-_--_-__ ❑ Distance to nearest lot line ....-- -- - - Remodeling 'nd/or repairing describe):__-�'? _�. _ -.------�xa- - ------------ gi d �/'� r ' --------------._--------- --------- -- ------- - - -- --------------------------------------------- -------------------------------------------------------------- • .... ... - ------- - ---- _Plod 4 -------- 115------� . ---- --------------------------------------- ---------------------------------------------- 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, and rules and regulations of the San Joaquin Local Health District. (Signed)- J I� .r r� AP1 -------------------( /or Contractor) f� By:---•--------------------------------------- •---------- ....... �' ----------------------------- -------(Title lf�C/L P - (Plot plan, showing size of lot, location stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED DATE �` 5�.= �♦ l REVIEWEDBY ------------- -- --_-------------------------- -- ------------------------------------- DATE------------- --------------------•----------------------- BUILDINGPERMIT ISSUED-------- -- - - -- ---------------------------------------------------------------------------------- DATE-- ----------------------- Alterations and/or recommendations.--------------------- --- --------- ---------------------------- ------------------------------------------- ------------- ------------------------- ---- --------------------------- ---- ----------------- -------------- -----------�-------------------- -------------- -------------------•------------------------ - --- --------------- ------- ------- ----------------------------------------- ----------------------- ---------•-------------- ---------------------------- -•---------------------------- ---- ------ ---------------- -------_------------------------------------------------------------------------------ ----------- --------- --- ------. •------------------• FINAL INSPECTION BY:- -- / -- - --- ----------- Date...... 64 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazetion Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi. 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