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FOR OFFICE USE: --------------------------------------------------------- APPLICATION FOR ANITATION PERMIT Permit No. ...... >�d 7 ----------------------- --- --I----------------------------- (Complete in Duplicate) �_�S --------------------------- _,____;___._..-. This Permit Expires 1 Year From Date Issued 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 C ------------ --- ---------- ----------------••----------------------' � - Owner's Name-- - G------ ------------------ ------ Phone----------------------------- Address---------------- -------------------••-------Address---------•------ ---f —} � --------- 7f Lr ------------------------------- ------------ ---------••----------•--•---- Contractor's Name------ •----------------------- K ----•-------------------------------------------------------------------------------••--•--- Phone------------------------ ------•- Installation will serve: Residence �Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -j--. Number-of bedroom_____ Number of baths -----/- Lot size _. ._...A-------------------------------------------- Water Supply: Public system ❑ Community system ❑ Private x Depth to Water Table ft, t Character of soil to a depth of 3 feet. Sand ❑- Gravel ❑ Sandy Loam ❑ Clay Loam Clay E] Adobe Hardpan ❑ Previous Application Made: (If yes date__________________.) No New Construction: Yes No ❑ FHA/VA: es El NoR TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank;or cesspool permitted if public sewer is available within 200 feet.) ._ Septic Tank: Distance from nearest well_..f ._ ___.Distance ry_fo..__ ation-fh No. of compartments--7--------------------Size-- -- ------ -_un------Liquid depth----- Capacity-_F-0:1 ------- - Dpol Field: Distance from nearer well____L __O?_.Distance from foundation-_; _C2_-___--Distance to nearest lot line- /._.. /1 Number of lines__..__I.................__-__ Length of each line--- 1--t�-�- -------.Width of trench._%?_ 4.......-_------_--- Tye.of filter_material_�__��` '" _Depth of filter material--./f --- p ............Tota€ length----- - _ r'--------------------- C Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to nearest lot line---.------------- ; ❑ Number of pits----------------------Lining material-----------------------Size: Diameter_---------------------Dept h---------------------_----------- F - Cesspool: Distance from nearest well--------------------Distance from foundation-------------- .__..Lining material-----------------------_-----.------ ❑ Size: Diameter--------------------------- Depth----------------------- - ----- --.,_Liquid Capacity---------------------- 9als.rt` Privy: Distanca from nearest well----------- ..----_._ ----- - -------------Distance from nearest+ building ------- ---- ___--_ _ .----❑ Distance to nearest lot line----------------------------- 7 ' I Remodeling and/or repairing (describe):---- 0-7 -- ----- -_ _ . -r�{_------ ----------------------------------------------------------------------------' --------------- ---------------------- -------- -------------------- -- r ----•- ------------ ------------- -------------------------------•--------------------------------------•-------------------------------------------------------------------------------------------------- ----- - - ---------- -------------------------------------------------------------------------------•----------------••----------------------------------------------------------------------•------------------------- ------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to lawis, and rules d®reions of the San Joaquin Local Health District. . , (Signed).- 1 -- -- (Owner'and/or Contractor) BY• ------- °' '_... _ _ --'��'-.-....._� 4�: _ -_ --------------------------------.--(Title)_- -..._ - (Plot plan, showing size of lot, location of system in relation tells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY -- ------ -- ---- ---------------------- -----------------------------------------,i bATE-------------V-L .__-, .-,---- APPLICATION ACCEPTED BY_---.--.----------- REVIEWED BY----------- ------- -- - - ,� , BUILDING PERMIT ISSUED - --------------- 1 ----------- DATE---------------------------- -------------------------------- Alterations and/or recommendations:-------------- ----------------------- ---------------------•--•--•--------------------------------------•------•------------: --------------------------------------------------------------------------------------------------------------------------------------------------•----------- --- ----------- --- -•- -- -------••-------------- FINAL INSI ECTION BY:-------- ----------- ------ --- ----- Date 2' ------ ----•i-- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California Es 9 REVISED H-59 3M 3-'63 F.P.CO.