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APPLICATION FO ANITATION PERMIT Permit No. -.1j.-Fr--6. (Complete in Duplicate) J��- This Permit Expires 1 Year From Date Issued Date Issued _______________ 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 Count Ordinance NZo5 9. Aj JOB ADDRESS AND L ATION------ �____ _ __ �f _ -------- --- Owner's Name----- + ---•--- - ---- - --------•--------•••------------------ ------------------------------------ Phone_ :•�I` �r - �j - �- ---e- , Address. f ----- - -- X Contractor's Name------ f { --- Phone- Contractor's 4 Installation will serve: Residence Apa ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/-._ Number of bedrooms _ ___ Number of baths _/___ Lot size d ,lQ_________________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table21111"ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan ❑ Previous Application Made: Yes ❑ NO New Construction: YesK No ❑ FHA/VA: Yes ❑ No�' TYPE OF INSTALLATION AND SPECIFICATIONS: (No(No septic tank or cesspool permitted if public sewer is available within 200 feet.) S4Seep tic Tank: Distance from nearest well-----------------Distance from foundation----_--------------_Material-------.______._______.___________.._____.____. No, of compartments------------- - ----------Size----------------------------•---Liquid depth..........................Capacity-•------------------ i ld: Distance from nearest well-------_---_-----Distance from foundation--------------------Distance to nearest lot line_______--___-____ Number of lines-----------------------------------Length of each line-----------------------------Width of trench-------------- ---.-- th tal : Distance Iwlell _ __�___ _D stars of friotmrf material dation____!!___/____-_Dostancengohnearest lot lin �.1�_�_._- s Number of pits......{__- ------Lining materia __.Size: Diameter__��------------ 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--------------------------------- ---------- ------------------ ---------------------------------------------------------------------- Remodeling and/or repairing (describe):___ --- -- - -.-----tom - --•------ - -••---------------------------------------------------------------------------------------- -------------- ------- -------- ---------------------------------------------------- ----- ----- --------------- ---- ---------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have pr ared this appli Pion a> d that the work will be done in accordance with San Joaquin County ordinances, State I and ules d regul ions the Joaquin Local Health District. (Signed ------ -------- -------------------- ----(Ow /or Contractor) B .--- - -------------- ----------------------------- -------------------------------------(Title) - J Y�------------- (Plot plan, sho g size of lot, location of system in relation to wells, buildings, etc., can be placed on re1ers eI. FO EPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- -------------- -------------------------- DATE Z -d - REVIEWEDBY----------------------------------------- -------- ----------------------------------•-------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------- ----------------------- --------------------------------• DATE-----------------------------_------------------------------ Alterationsand/or recommendations:_------------ -------------------------- --- ---------------------------------------------------------------------------------------------------------------- ------------------ ---- ------ - .� , i+ �- fJ l FINALINSPECTION BY------------- ----------------------------------------------- Date------------------------------------------- -- -- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wesf Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 6-'59 F.P.Co.