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FOR OFFICE USE: .__. APPLICATI{(Complete i OR SANITATION Duplicate)pcat} PERMIT Permit Na. ; :� ----- This Permit Expires I Year From Date Issued Date Issued ._l:__, 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. rr ! JOB ADDRESS AND LOCATION t-r` ~ _- -�_c ` 'r'}`r' Owner's N - �- �L Phone---- ------------- a Address -------- -----� _ =�' -------- ------- ---- Contractor's Name Z' ------------- - ----- Phone (" Installation will serve: Residence Q""Apartment House ❑ Commercial ❑ Trailer Court E] Motel E] Other [-I Number of living units: Number of bedrooms Number of baths _/_ Lot size nl" ! ----------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -�Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Er Hardpan ❑ Previous Application Made: (If yes,dote _-- -- .----.-) No [�' New Construction: Yes ❑ No Q-" FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) c,Tpk: Distance from nearest well_-__---____.. --Distance from foundation........ ........Material--.-_-- --- ----.-.-.-.--...------ ----------- No. of compartments_. ---•- - -- - --------Size-------- --------Liquid depth---- ----- ---- - ------ Capacity isposal Fielu: Distance from nearestwell '- �.a!':.-------_-Distance from foundation--_2..!"°_.......Distance to nearest lot line".. -._r.-.-"" Q' Number of lines-------/-----. -----•.-- .- -.-._Length of each line--.F.G`----------------- -Width of trench-..------ -_ .."--.---_----- Type of filter material"_ -/ J .�/r'-,Depth of filter -_-_Total length.---, ----------- --- -_ - ----------------- Seepage Pit: Distance to nearest well.. _-_-------_._-__Distance from foundation--------------------Distance to nearest lot line-------..---...._ ❑ Number of pits_--------------------Lining material..-----..- -.----.Size: Diameter------------.- ---------Depth -- - -- -------------- Cesspool: - --- --Cesspool: Distance from nearest well-------------__Distance from foundation ------.-.--__ Lining material------ ---------- ❑ Size: Diameter- - ------ --- ---- - - Depth -- ---- ------- Liquid Capacity- ------------- ---------gals. Privy: Distance from nearest well----. Di ❑ Distance to nearest lot line- stance from nearesf building ----- - - - ------- _- Remodeling and/or repairing (describe):- ---- -------- - -- --- ------- ---------------------------- -------------------------------------------------- ----------- --- Iherebycertif that I have Y Y prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rule, and regulations of the San.Joaquin Local Health District. --- m ° Y ------------- (Plot ` s `_� r � _- t c � I .._ � -- -- -- --------- O ner and/or Contractor} (Signed) `4+ Plot Ian, showingsize of lot location of system .al -- _.�' - . Title .�,� - y in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- : ------ j DATE. �- --- . —--- ---- REVIEWED BY BUILDING PERMIT ISSUED-------- - DATE------ - ---------------- ---- ------------__ ------- - . - Alterations and/or recommendations_ _____ --- --------- --------- -- - ---- - ------------- ------------ DATE.---------- ------ --- ______________ ___ " --- -- ----- HNAL INSPECTION /,? BY: ...... r�= r 1,L ------ Date-_. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 724 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy, California F.P.C U.