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APPLICATION FOR >_ANITATION PERMIT Permit No. (oaf (Complete in Duplicate) i Date Issued Application is hereby made to the San JoagJ Local Health District for a permit to construct and install the work herein described his application is made in compliance with County Ordinance No. 549, 1 JOB ADDRESS AND LOCA ------------------- ame-- Phone- y1.��1 Address--N �--�.---- ` --- -�` -- �- ------ --- ----------------------------------------------- ------------ -------------------------- Contractorl Name----- __ + -------------` ----------------------= -------------- ---------------------------------------------------------------------- Phone ---- ---------- --- Installation will serve: Residence Apartment House`❑"'CFm—mi rci'a`I'❑'Trailer Court{]Motel Other ❑ Number of living units: _� Number of bedrooms _ Number of baths _/_-_ Lot size ---------------------- Water Supply: Public sysfemg Community system ❑ Private ❑ Depth to Water Table tt- Character of soil to a depth of 3 feet: Said ❑ Gravel ❑ Sandy Loam ❑ bay Loam Clay Y ❑ y ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No 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.) 5 T Septic ank ' � icompartments nearest well---------- , _Distance from foundation_--_----_'--.------.Material-----_---- ---------- No. of _ ---------------f-----Size--------------------------------Liquid �_---. ---- depth=_`i ----------------Capacity Disposa 41 J: Distance from nearest well_-------- ------Distance from foundation_---_.___.---.----.Distance to nearest lot line--_----_-_-_-__. Number of lines _---i_______________!___--Length of each line---------------------------------------- ----Width of trench----- ------------ --- . Type of filter material------------------I------Depth of filter material.._.-_---_-__-__-_ _-Total length ------------------- }- Distance f om f ndatio Distance to nearest lot line-� �_____ Seepae Pit: Distance to nearest well_,"`_-_- Number of pi#sf----1-______Lining material- Size: Di eter--_- ' ---------Depth Cesspool: Distance from nearsstlwell-----------------Distance from foundafion_--------.--------..Lining material------_-_-------_ i ---------------- l ❑ Size: Diameter---------------------------------�-- --Depth--------------------------------- ------------------Liquid Capacity--------- ---------- ----gals. a I "a F Privy: Distance from nearest .well----__---_1_r_- ( -- - -------------------_-Distance from nearest building g ❑ •�--•--Distance•to-nearest='lot�hne_________----_____-__ _ ------------------------- ___ _________ ______ Remodelin or repairing (describe):_- ' r� -s =-------------- - { -- -------•----- ------------------------ ---- -------------------------------- ---- - - I hereby certify that I have pre ared"hi%./applicati n and that the k`will`be dane`in accordance with San Joaquin County ordinances, fe law rules a re ations of t San oa uin al Health District! (Signed)- ' ! I ---- -�-f---- -.-' -(Owner an or Contractor) gy:------- ------ ------ y -----[Title) T -• ; s [Plot plan, sh "r s1z of ! a afion s stem in relation to wells, buildings, etc., can beep ed on re rse s' f' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- #r -- ----- ---- ----- - ----------------------------------- -- DATE---------------------------- } - ----- --------- - ----------------- ------ DATE o BUILDING PERMIT ISSUED_____________ i ----------- ------------------------------------- D Alferafi s an or.rec`ommendat' nsi_ - 1___---____-- ATE------ ------------------------- /3� ' � - ---- -� - -------------------------- +.y y-------------------- --------- -----•-^----------•- ----------•-----------• ----------------------- 4 ------------------------------------_-----•---------------------------------- ---------------------------- ------ •------------ ----------- r FINAL INSPECTION BY: Date- ---------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California r E5-9-2M Revised 1.57 F.P,CQ- i ,