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FOROFFICE USE: 11 j� 0 ZC) (0 IOR SANITATIOr ---------------------------------------- ---- ----------- APPLICATN/ . PERMIT Permit No. __-- /-�_- f ------------------------------------------------ ------- (Complete in Duplicate] -- Date Issued ----- __bJ ---------------------------------------------------- - This Permit Expires 1 Year From Date Issued .— Application is hereby made to the S n Joaquin Local Health District for a permit to construct and install the work herein described. This alp 11C.0 tion is-mid - c m li c ith'� my Ordina ce No. 549. ;W 7xe: k"a . j e't � 0114- JOB`�DDRESS (ANDD LOCATION__ .-- - ---- -- ---�-� ----- -- �- ---�- - - �G{ Owner's Name--- i-•-=C/ - ------ ---------------------- ------------------------ ------ Phone-EA/- ------- ---- ------ Address-------------- ---Address-------------- .... -- --•-•---• ' - -- -- --a Contractor's Name---- -- - - - -- e I ............ Phone.------------------------ -------- Installation will serve: Residence ❑ Apartmen House E] Commercial ❑ Trailer Court E] Motel ❑ Other Number of living units: __ __- Number of bedrooms -------- Number f baths _L__.._ Lot size _ _ _______________________ Water Supply: Public system ❑ Community system [-] Private Depth Water Table _______ ft. Character of soil to a depth of 3 feet-,Sand E] Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: {If yes date_,_._______,.`_; I No.❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: tn septic tank or cesspool permitted if public sewer is available within 200 feet,) Septi k Distance from nearest wall-_a;A_.�_._D.istance`from foundation__-_C_l-------_-.Material_____ __________________ No. of compartments_ .__.....__ �f`'�D ______ q p. p y. -_------Size_ S'__-___Li Liquid de th_____ ________________Ca acct d_ / i Dispos Field: Distance from nearest well__-_,�0----Distance from foundation___�_I�__-------Distance to nearest lot liner.___.___. Number of lines.__.____ ---__________ ` - --------------------Length of each Imine --��---_------Width of trench---e�_ - T e of filter material- De th of filter material_____ �� $ee � Yp - - -Depth /S ---------Total length----- -�1-----------------•- page Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__.__--_____---_. ❑ Number of pits----------i-----------Lining material---------- ------------Size: Diameter-----------------------Depth_..---.------- --_-_ Cesspool: . y Distance from nearest well-----------------Distance from foundation__________ _______ Lining material-------------------------------------- ❑ Size: Diameter-------------------------- ------- -De th----------------------------------------- . ✓ P ----------Liquid Capacity------ --------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building_.___...____----- ________ --___. ❑ Distance to nearest lot line---------------- ---------- - ---------------- ------------------------------------ Remodelingand/or repairing (describe)= --------------------------------------------•--------------------•---------------- ------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------=------------------------------------------------------------------------------------------------------------------ I ------------- I hereby certif that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State and rules and regul tions of a San Joaquin Local Health District. (Signed)-------------- - V --- - ---- ----- - ---------- - ------------------------------------------------- - -w!trtef-- d/or Contractor) By:--------- - ------- ----- --------- - f.- - -- --------- -- ---- --------------------------(Title)-------------------------- --- ------___._.---------------- + (Plot plan, showing size of lot, location of system rela ion to Is, buildings, etc., can be placed on reverse side). FOR DEPART ENT USE ONLY A _4 ( ---------------- APPLICATION ACCEPTED BY_- DATEe REVIEWEDBY ------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED----------------- ------------------------------- -------------------------------------------------- DATE-------------------------- ---------- Alterations and/or recommendations------------ ---------- ------------------------------------------------------------------•-----•-•----------------•---•-------•------------------------------- -------------------------------------------------•------------------------ ------ ------------ ------------------------•--------------------------------------------------------•----- ------------------------------------ ------------------------------------------------------ --------------------- ------------= ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------_..----------------- - -- �------------------------------•--------------------------------•-------------------------------------------- ---------------- -------- FINAL INSPECTION BY:-- ------- ------------- Date ?��- -------.------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Nazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street V Stockton,California Lodi,California Manteca, California Tracy,California ES 9 REVISED B-59 3M 3-'63 F.P.CD.