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R OFFICE USE �• t � -----------------f ---- .---.___ . • --- - --{O.. �� .-� .- APPLICATION F6?�SAN�TATION PERMIT Permit No. _ ------------- ------- --------------------- (Complete in Duplicate) =-. This Permit ----------------------- Expires 1 Year From Date Issued Date Issued _5------------------ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the wor ereiin descy yyribedj. This application is made in compliance with County Ordinance No. 549. � `!10,m' ,/epi .e_ -- _-J1JOB ADDRESS AND L CATION----� 1 ------------------------c_ --------- ------• -. ---- - ------------------ - ------- Phone----•---------------- � 'Owner's Name ---------- 0 .f_ •• Phon , Contractor's Name-------------- --------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial A Trailer Court ❑ Motel 0 Other ❑ Number of living units: -40- Number of bedrooms -__ - Number of baths --2-. Lot size --- Wafer -Wafer Supply: Public system 9 Community system ❑ Private ❑ Depth to Water Table _oft. 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 Q( New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t r Septic Tank: Distance from nearest weft----+56-.---Distance from foundation---/0----------Material .__--. ..__ No, of compartments----------2-_- ----_____Sill------$-k-6_ 10---Liquid depth______._...... _._Capacity-1 Disposal Field: Distance from nearest weflG-_�-Distance from foundation.-/a--- .-----.Distance to nearest lot line-- [ Number of lines---_--- -__-- -.___ Length of each line----S� --- Width of trench..._ ----- --____-- Type ' filter material--- 7Q-__O __ --Depth of filfer material--- -__� �v Total length----- Seepage Pit: Dis#ante fio nearest well__ ��.%----Distance frasm��f undation_-IQ_-_...___.Drstance to nearest lot line---�-�..- (, Number of pits....._.Z------------Lining material----A04 .----Size: Diameter------7_ --------- Dept h-------c4---_f---------- Cesspool: , -----_-Cesspool: Distance from nearest well-----------------Distance from foundation------- -------- -------.-----Lining material- ------------------- ------ ❑ Size: Diameter '- -----Depth--------------- ------------------------------------LiquId Capacity-------------------------- gals. Privy: Distance from nearest well------- -----------------------------------------Distance from nearest building ❑ Distance to nearest lot line------------------------------------------------•-----_ -- Remode,ing and/pr repair g describe)=---- -L��'-�`�' ------------ ------------------------ --------------------- --------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 +he San Joaquin Local Health District. s (Signed) ------------- -------------•-- (Owner and/or Contractor) I --------------------------------------- By:-------------------• t r= (Title) (Plot plan, showing size of lot, location of system in relafion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY } APPLICATION ACCEPTED BY-------•----- -------- ------- --------------------------------------------------------- DATE-----j'_7 REVIEWEDBY ------------------ ---- ----=--:------------ ------ DATE BUILDING PERMIT ISSUED ------------------------------------ DATE----------------- lta+io s and/or recommendations: --------------------- ------------------------------------------------------------------------------------ --------------------- --------.--------- r ------ -------------------------- ------------------------------------------------------------------ ----- �.� .---------1p�---------------------------------------------------------------------- ------- ---- ------------------- - ----- ---------------------------------- -- ----- --------------------------------------- .............................. ------------ -------------------------- - ------ FINAL INSPECTION BY---------------IlxrrC ------------- Date-------------- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California C.P.CO. + r 1