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FOR OFFICE USE: ------------------------------------------------------ APPLICATION FOR GANITATION PERMIT Permit No. .. .__ --------------------- ll - ----------------------- --------------- - --- (Complete in Duplicate) - Date Issued ..-----------/b--� `'..__ This Permit Expires 1 Year From Date Issued t Application is hereby macle:�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. 0 e- Fx/r—_ JOB ADDRESS AND LOCATION. �. �_r-- --•----- - - _.; _, __. _._ ------------------------------------------------ Owner's Name------- fG' - 'a - •--------------- ------------------ -- Phone..._.. II Address----•-----------I X--C 4 `'--------------�--------------------- -------.-_-------... Contractor's Name,.-------- - -- - L. •- ----------- Phone.....................------•------- installation will serve: Residence .® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /------ Number of bedrooms __ '._ Number of baths ly_ Lot size -4 0_11t�------------------------------------------- Wafer Supply: Public system ❑ Community system •❑ Private © Depth to Water Table 4., ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [] Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date ----------.........) No mr New Construction: Yes,4 No ❑ FHA/VA: Yes ❑ No ❑ 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__Sbf------Distance from foundation___1�'________.Materiai________________________________________________ ,t 4 No. of compartments---m� ----------- Size__ :_..Liquid depth-------/-----------------Capac ty p 'Y i Dis osal Field: Distance from nearest well�a_______.__.Distance from foundation..--/-0_____.._-Distance to nearest lot line_- '_______ Number of lines-------- - -- --- ----- ---Length of each line_____ - ----------.Width of trench.-✓�- -------..--------------_---•- Type of filter material/ - -_ Depth of filter materiaL_�_ ______________Total length__/�0._____._._________..._________-- Seepage Pit: Distance to nearest well________ ------------Distance from foundation....................Distance to nearest lot line----------------- H iumbe1r of pits______________________Lining material______ ----------------Size: Diameter------------------------Depth--------------------- ----------- ❑ Cesspool: Distance from nearest well__4._______-__-Distan�c�efrom foundation___________________Lining material-_._________--_____.______________._ ❑ Size: Diameter------------------------ pth --------------De - . ------------ ----------------- °-- --Liquid Capacity gals. Privy: Distance from nearest well________________.________-_.__.___.__________Distance from nearest'building_______________'Y-._________-.__..__----. ❑ Distance to nearest lot line--------------------------------------------- --------------•----------•------------- ---------------------------- j -- - , Remodelingand/or repair:ying (describe):--------------------------------------------------------------------------------------------------- --------------•-•------------------------------------ E ----------------------------------------------------------------------------------------------------------•-------------------------------------- -------------------------------------------------------------------------------•---------------------------••---------------- ii /_1 1 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. �"� I � 1 ' -11 •'t/,�` �� "- ------------ -------------------------- ---------------------- (Signed)------- (Owner and/or Contractor) � --------- -. ----- ,r - By: -----------•------- -------I---------- ------ --------------------------------------- ---------------------------------------------(Title) ------- ------ ---------- ---------- a (Plot plan, showing size of',lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). c FOR DEPARTMENT USE ONLY rn APPLICATION ACCEPTED BY__ . DATEP-W_76C-------------------------------------- REVIEWED BY-------------------<------------------------- ---------------------------------------------------------- DATE 1 BUILDINGPERMIT ISSUED----------------•------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations-------- ------ ------------------- ----------------------------------•-------------------------•-••------------------•-------•---•------------------ ---------- -1------------------------------------------ ---------------------••---------------------------- ------------------------------------- -------------------------------------------------- ---I------------------------------------------------------------ -------------------------------------------------------------------------------------- ---------------------------- -------------------------- --- -------------" - ----------------------------------------------------•----------------------- -•--------------------- -- l -------------------------------------------------------------------------------------------- ------------------------------------------------------------ ii . fl FINAL INSPECTION BY: - -------------------------------- - ---------- Date-.,7-- ----------•-- ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT i 16o1 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California :+ E5 9 REVISED 8-59 3M 3-'63 F.P.CO.