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FOR OFFICE USE: i APPLICATION FOR '`ANITATION PERMIT Permit No. _""......" ..a_-. ��-------------------�f {ComFZ+e' -"Nuplicatel -------- -------- ------ ----------- --------------- This Permit Expires 1 Year"::From Date Issued Date Issued } Application is hereby made to the San Joaquin Local Health District fa; a per it to construct and install the work herein described. This application is made in compliance with County Ordina N 541'% JOB ADDRESS AT CA N-------3 7/.i0_ S �: • - ----- Owner - 's Name -- ---- --i--------•- -------- -------------- ---------------io------------------ Phone Address------------------- ---- : Contractor's Name-------- - "� _ Q - ----------------------------------- Phone; _&QQ_�07".. Installation will serve: Residence ;K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms __.Number of baths_�__- Lot size �.-�_ ' Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 4 ft I Character of soil to a depth of 3 feet- Sand ❑ Gravel Sand Loam Clay Loam Clay I \t - ❑ Y ❑ y ❑ y ❑ Adobe � Hardpan ❑ V Previous Application Made: [If yes,date_----------- ------ l No New Construction: Yes ❑ No FHA/VA: Yes ❑ No V TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--?.�_ ... Distance from founclation./0___._--"--,Material "" �- No. of compartments-. __Li Liquid de th_5.=2 ft . d p - -------------------Size�.X.�-X�- _ q p -- -Cepaclty"��Q"" ,. Disposal Field: Distance from nearest weIL1O..........Distance from foundation__Z --_--"""--Distance to nearest lot Gne_25i�1 Number of lines ------- Length Width of french-2-41--1____ -�---_"---- Len th of each line-- - -----'----_"-- Type of filter ma#aria(- Depth of filter material...1_ _.---------Total length-.- j-_ ......... Seepage Pit: Distance to nearest well.---------------------Distance from foundation-.-_.----------.--- Distance to nearest lot line---------I_.__:" ❑ Number of pits Lining material. - ---- Size: Diameter---------- ------ ---- Depth--- ---------------------J- ------------------ -I- - Cesspool: Distance from nearest well ---------- Distance from foundation., Size: Diameter- -- ------- - ----- ----- -- -------Depth--.---------- -------------- .... ------ ..Lining material._..-__._"_"_".__ = ------ ---- ❑ ...... ------------ Liquid Capacity------------------------- gals. f Privy: Distance from nearest weil _..._'_Distance from nearest building ----- ❑ Distance to nearest I ine___ ... ..........____---------- Remodeling and/or repairing (describe):-_ !111"i Il --- -----------•------ •----- ----------------------------- --------- ------------- -----------------------------------------------------------------------------------------•------ ---------------------- ---------- '1 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)._ I9_-. 5 -------- -- 0•-- - -- (Owner and/or Contractor) Sy:---------------- a_. 1 (Title}-- - - - �. ... (Plof plan, showing size of lot, Iota+ion of system in relation to wells, buildings, etc., can be plat an reverse side}. F DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--_. ----- _ - --- - -- --------------------- ---- -------------- DATE.----- ------------------ ,> REVIEWED BY ----------------------- S---- ---- .------ ------ DATE BUILDING PERMIT ISSUED-------------- .................. ,. ------- --------------------- DATE ------------------------ Alterations and/or recommendation :..______ r ---------- ^------------------ --- ------ .. -- iI ---- ---------------------------------•----- -..--------------•------------ .. ------------- --------------- FINAL -FINAL INSPECTION BY--------------- ------ - -� ----- • - - ------------ Date----------- =-- - - - �. SAN J UIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street Stockton,California Lodi. Cal;forniakM205 West 9th Street anteca,California E.H.9 2M 1-67 Vanguard Press Tracy,California