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APPLICATION-FOpiete RSANITATION PERMIT Permit No. -,-""_- (Co min Duplicate) � s Date Issued --- ----------� - Application is hereby made to the San Joaquin Local Health District for a permittoconstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. ( aOLt p4� JOB ADDRESS A LO ATI N _ -�{�. ---- -- . --Xp. x" - "/j-- -`''�` --------------------- Owner's Name----- __ = ---------- =---�--------------------- ---------- Ph ne.------•---------------------------- �_ ;u' �' ----- r- ---------------------------------------- Address_Contractor's Name - ------- -------- Phone-"--------------------------------- _,..�,,,,,._,..,..,,.�,�-.„,, _, Installation will serve: `Residence'[v�Apartment House ❑ CommercEal'� Trailer Court � Mofel ❑ Othe ❑ J.living units-. __I-___ Number of bedrooms __Z_ Number of`baths ._�_-__ Lot size _ ------------------------------------------------ Water __�_'_��_ Number of ------------------------------•- Water Supply: 'Public system �Commun'ity system ❑' Private ❑ Depth'to Water Table ----- __ ft. " Character of soil fo a depth of 3,.feet:'- Sand Gravel ❑ Sandy Loam ❑,` Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction:'Yes [df No;l] FHA/VA: Yes!❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank ok3 cesspool permitted if public {ewer is available within 200 fee .) Septic ank: Distance from nearest well HO.__�Distance from fou dation_`0____________.Mater.i i__._ .._.9--_._"_____� No. of c'ompartments-----------� �_.---'-Six r Liquid depth-----------�r--------Capacity_- _ ----��r----_� Dispos Field: Disfan e'"from nearestwel_ __ ___________ istance from foundation_��Distance to nearest lot ine_"�'��' [ Number of lines__________ _ _ ---- "Length of each line_+ _)C _ _d_ _Width of trench...._______ I,-- T filter'mate�.i ' Depth of filter material_____1_ ��_____Tota! length_____"-___� ___________________ Seepage Pit:x , Distance rto nearest Distance.from foundation__"_-_--___"--___"-.Distance to nearest lot line_________________ ❑ Num,e'r.of(pits l: ---=':------_Lining material---------------``-----'Size:'Diameter----T:�_._.-------------Depth-------------------------------- Cesspool: _,.DistAce_fjz m. ..nearest„w 'll......_..:.-----:Distance f 2om!f.undefion__.:---:_=_-_"__.Lining,material _"""__"-"-."_"-"-"."_----------- Size:lADiameter ---- ------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Y: i Pr-iv Distance from near-est well___________________________"._= ---- __,Disi-ance from nearest building__-.....__________________"___-__________ ❑ Distance to)nearest-lot de =---- -------------------- -------------------------------------------------------------- ----- Remodelin nd/or rep"in-g-f-jee}:- -- ':_ -----------------•-------------•-----------------•-------------•-----------------•------------------------ --- -----=------------------------------------ -------------------------- = : - -- ---------- ---------------------- ��-- -_- � �- = _ �----- ---__-__- -_--_,�-----�..---------------------- I hereby L certify that l h4vt prepared this application and that the work will be done in accordance with San Joaquin-County ordinances, Stat aws, an rules and gulations of the San Joaquin Local Health District. •-s � (Signed) Owner and or Contractor By=------------ -- = °Lr = (Title) (Plot plan, showing size of.io , 'o tion of system in relation to wells, buildings, etc., can be placed on reverse side). o� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY� ---------------------------------------------------------------------------=--- DATE4------------------------------ ---------------------- REV BUILID NG PERMIT ISSU ------------------------------------------------------------------------------------ DATE ED-------------------=---- -------------------------------------•-------------------------------------- DATE- _ --------•----- ---------------------------------- Alterations and/or recorriinendations------------------------------------------------------------•---------------------------------------- ------------------------------------------- - JI . ------------------------------------------;------------------------------------------------------------------------------------------------------------------------------ T �+g3"ff ---- 'i�*-•w-_.�- �c�4-- - �--- ----- ---- _ -•�_!- -- -tx-"� `=p-t-�f�---------------------------------------- ----------------- -� U FINAL INSPECTION BY:_- ._. . __-._ `5� ' 1 =_-- - --------------- ----- Date 7 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, Californial' Lodi, California Manteca, California Tracy, California II r ES-4-2M . Revised 1';57 F"P.CO.