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FOR OFFICE USE: --------------- ----------------------------------------- -------------- _ ---___________________________..__..___.._____..._.___._. APPLICATION FORytSANUATION PERMIT Permit No. ...... - --- ---------------- ----------------------- -------- (Complete in Duplicate) ---.--- 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 compliances with County Ordinance No. 549. F JOB ADDRESSD LOCATION----9_a1 D-.._ _ q Owner's Name(n ---------------------------- ----------------------------------------------------------------- ---------------- Phoned �'�1 1---•--- Address---- _ Contractor's Name -__.G�. ---•------------•----•------------ --------------------•---------------------- ------- Phone----------------------------------- Installation will serve: :Residence Apartment House Commercial ❑ € p ❑ ❑ Trailer Court ❑ Mote! ❑ Other Number of living units: _ _-__- Number of bedrooms 3 ._ Number of baths J___ Lot size ----- ---to. r Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. s t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [) Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made. (If yes,dafe-----------:........1 No� New Construction: Yes No ❑ FHA/VA: Yes ❑ No � I, TYPE OF INSTALLATION AND SPECIFICATIONS: / (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well 0-_____Distance from foundation---�O_J_____-_.Material-------- __ i [� No. of compartments ` -- Size. X 4`� Liquid depth Capacity g , p�%r : Distance from nearest well__---..____.Distance from foundation___�__�----___._.Dlstance to nearest lot line-----R_-__-__ tU Number of,440rs_f&--------------------------Length of each line--------(-0- ------------ .Width of trench------,-0'-------------------- Oa Type of filter materialAi--_Depth of filter materiai---- �______ ____Total length___.-l.d _ y_ _------ Seepage Pit: Distance to nearest well--------------------- istance from foundation-------------------.Distance to nearest lot line--------a'------ Number. of pits---------------- -----Lining material-,--------------------Size: Diameter-----------------------Depth---.-----------------------------wI Cesspool: Distance from nearest well-____._____..:__Distance from foundation____________ ____ Lining material _ material_ .____.______-___-____.___._________ ❑ Size: Diameter----------- --------...- Depth `===------ � - -------------- -___________Liquid Capacity------------ -----------gals. Privy: Distance from nearest well---_____________________. ._ . ..........Distance from nearest building--------------.______- -------------------- - ❑ Distance fo nearest lot line--------- ----- --------- ---------- ------------------------------------------------------------------- ----------------------------- . Remodeling and/or repairing (describe):----------------------------- =--:---------------------:----T ! Lic -- ---- -- ---- ------ ----------- .-- -_'�_ ___ ¢rnn--------------------------------------- ---- ------ ----------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- - -- -- ------ 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) -------a�_ . -----------------'__.-.`----------- ---------------------------------(Owner and/or Contractor) _ gY:----------------------------------------------------------------- r - (Title)------------------- -- I I (Plot plan, showing size of lot, location of system in relation to wells, buildings,�etc., can be placed on reverse side). --7.e r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- _ - ---------------- ---------------------------------------- DATE-- REVIEWED ATE-REVIEWED BY------------------------------ --- --------- ------------- ---- ---- ---------------------------------------- DATE----- BUILDING PERMIT ISSUED------------------------------------------------ -------- ------------------------------------------- DATE - �..,,._ -�..�,.,-...- �w ,_T _ Alt�atio s and/ r recommendations:- -- ---- -- -- �-�--� --------�--•----w—�--� --------••------------- -- . f ---------- ------ ___ __________ -------- ---- --------- __ -----_ _ __ r C/>7 f - r � --- ------------------------------ -------------------------------- --- FINAL INSPECTION BY:__ � - - . � •--------------------- - Date-------- - -----.�_L' `�`---�---------------- ------------------------ 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 ; F.P.0 O. ,.. gr