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APPLICATION FOR,.. ANITATION PERMIT Perrriit No. ?V1 (Complete in Duplicate) Date Issued •----•---- ------------ Apon 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. $ JOB ADDRESS AND LOCATION__._ ----- --------------------------- --------------------------------------------------- ---------------•------------ Owner's Name---------- ---------- - -_ Phone- Address h --------- - one- • ----5-'"-- Address--------- !- :.-•t Contractor's Name Si. --------- -------------------------•- -------- I- ---•------------- Phone-- -2.. .. • -------•-- Installation will serve: Residence Apartment House [:] Commercial "❑ Trailer Court ❑ Motel ❑ + Other ❑ Number of living units: Number of bedroom`s .'n- Number of baths -1.... Lot size - --Water ------------------•------- Supply: Public system �ommuriify system ❑"'Private ❑ ' Depth to Wafer Table Character of soil to a depth of 3 feet: {Sand [2 Gravel ❑ Sandy Loam ❑ Clay-Loam' ❑ Clay ❑ Adobe Hardpan ❑ 01, Previous Application Made: Yes E]- No ( New Consfruction: 'Yes No ❑ a 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 $.------Distance from fou dation-__ �__�-----__.Material- '____-- No. of compartments_.._9n-----------------Sizetw_ _! _�]- ---Liquid depth-e'f_-4�----------Capacity--- Disposal Fields Distance from nearest well*nQ--------Distance from foundatio _ ,_--__Distance to nearest lot line______._____ Number of lines------:---!------- ------------ --- Length of each line----- ._�_* -_------..Width'of trench- -- -- ---------------- � pp Depth of filter material-_-._.�_ ��_____--Total length___-------------------------------------- Seepage, �'__�_____ Type of filter. materiaL__1�!?�__ , See a e,Pit.- Distance to nearest well_ "' - �:w p g .- Distance from foundation___.._.: _._ Distance fio nearest lot I-- �-__----- p , I g , Number of its____ ___________Linin material_ :_____ __.Size: Diameter_ 7Y e Cesspool: Distance from nearest well................._Distance from foundation-___ ____:___-____.Lining material--------------------------------------- Size." Diameter------- -----------=------------ ----Depth-.--.----------------- - -------"Liqui:d Capacity_._.. -------gals. \ Privy:, Distance from nearest well_______________--------------------------------__Distance from nearest buildingp 'Distance to nearest lot lone'- " - , ------------ ---------------------- ------------------------ Remodeling and/or repairing (describe]:_'_' ) -------------------------- --- ---•- --------------•-----------•------ --------------------------------------------- --------•------------••--•------------- ------------------------•-----•----------- ^ » - •-• •-----------•---------------•-•-_'.-------.._._•_----- ... ------------------------------`--- •----------••--- -`----. ___---••----------------- ..-----__• --•--------------- -------•------•-----e-------------------------`•---•-----...-------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin CoyntyL- ordinance ata laws, and rules and regulations of the San Joaquin Local Health District.' (Signed) -------- ------------------------------------ -------------------- -------------------- ------------------------------------- --------- ---- (Owner and/or Contractor) By:--------- ... ••• ----- ,_---'------ -= •------------ ----------------------(Tit) �.,�Ah-`---•----------- r e) Pot plan, showing size lot, location of,systeni in relation to wells, buildings, etc., can be'placed on revers side). J # FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- - --_-,�� --_ ?---. DATE------------- ------_ ' i REVIEWED BY ` >� '"' ------ ---- DATE----- f �-'S `r BUILDING PERMIT ISSUED------------------------------- l ---------------- - I I-•-----•------------------------------------- DATE ------------------------------•----- Alterations and/or recommendations---------------------_... r_ `__..._.. r r� _.1.•---Vit.----�----•----•--------�---g-•`�{�-�'----:'"-�-�� .1-�_= ._rte'= ,'-----� ��`..`- ---- ---------------•----------- ------------------------------------------------------------- F 4 --------------------------••-----• ` --- ---------- OAII ---------- F1NAL INSPECTION BY::_: w 1 Date... } SAN JOAQUIN LOCAL HEALTH DISTRI T # 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-2100 ,