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FOR OFFICE USE: 5 APPLICATION FOR SAN TATION PERMIT Permit No./l._�. ----.- (Complete in Duplicate) --------- Date Issued This Permit Expires 1 Year From 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. -jj f Ip_ O G1C i{`gf W. �G�11 iEwJ T� S I' t JOB ADDRESS AND C TIONp `' ----------- ------ - ----------- ----------------------- � . Owner's Name�-- " i1f_ _ --��---------------------------------------------------------------- ---------------- Ph . ----------•----------------------------------•---- .. . -------- --------------I-- ---------- I------- -------------0�._e Contractor's Name--------- --- fQ` � �T Phone Installation will serve: Residence ❑ Apartment Ho ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ Number of living units- -------- Number of bedrooms -------- Number of baths -------- Lot size ________.___� -- ---t-------•--------------------•- Water Supply: Public system ❑ Community system ❑ Privatev, Depth to Wafter Table -- , ft. Bvz Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ ndy a Clay 4Oam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (if yes,date.________.__..__.._) No ` w onstruction es ❑ No�FHAIVAA. Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: T Distance from nearest well_________________Distance from foundation-------------------Material-------------------------____________._._._____ No. of compartments------ -------------------Size--------------------------------Liquid depth---•----------------------Capacity---------------------- Disposal I;Iel : t Distance from nearest well-----------------Distance from foundation...-_.-------------.Distance to nearest lot line-------------_.-_ ❑ Number of lines-----------------------------------Length of each kne-----------------------------Width of trench------------------------------------ 4-, Type ------------- _----------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------.----- I Seepage Pit: Distance to nearest well_._.�__2_____Distance from founds 'on___'�_p___. fiance t nearest lot line-_L� 1 Number of pits ----------- �i er' ,� � is eter- Depth- l��K Cesspool: ------------ Distance from nearest well_______________ _ Istance from fo nIon....--------___.___.Lining m terial--------.---_____.._______-_______- ❑ Size: Diameter- ------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------.----------------_____----.___Distance from nearest building_______.______-_-__--________..___.____-. ❑ Distance to nearest lot line--------------------------------------------- ---------------------- ------ ----------------------------------------------------------- (� Remodeling and/or repairing (describe)----- , -- ----- -•-- -------�---------------------------•-- C ------------•----------------- - -°-------------------------------------- '------------�--------- IV------------------------/ --------- •• ------------------------------•------------------------------•---------------------- -----------------------------------------------------------------------•---------------------------------- ------------------.----------- 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 a re tions of the San Joaquin Local Health District. (Signed)-- - - ------ --L = - -- -- �� -- -- -- ---------------- ------(Owner and/or Contractor) By:-------------------------------------------- ---------------------------------------------------------------•---------------------(Title)-- ------------------------------------------ - - -------- - - (Plot plan, showing size of lot, to ion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------------------- ----------------------- ---------------------------------------- DATE------------------------------------------------------------ REVIEWED BY --------------------- !--- DATE -r BUILDING PERMIT ISSUED-------------------------------------------------------------- DATE.----- ------ J_ ---- ----------- �J Alterationsand/or recommendations------------------------------ ---- -- ------------------------------------------------------•--•-•---------------------------------------------------------- -------------------•-----------•------------ ---.--•--------------------------------------------------- -----------------------------...------------------------------------------------------------------------------------- ---------------- ------------------------------------------------------------ ----------------------------------- -----------------------------------------------------------•------------- --------------------------------- -------------- ----------------------------------------- ----- ----- ----------- ------- --------- - -------------------------------•------------------------------------------------------------------------------------ FINAL INSPECTION BY-- ----------- - - ---------------- ----- Date------- ------ J� C� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Mantecar California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CO.