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t APPLICATION FO, jANITATION PERMIT Permit No. (Complete in Duplicate) ��y / 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 County Ordinance No. 549. JOB ADDRESS AND LOCATION------- --. -----------S"�_Q--------------`-------- Phone --------------------- -------------------------------- Address-.. -----`�7-- Owner s Name � -�u cna�.�---- ---------------------------------------------11-------=--------------------- 'C -` d- a � k i Address-----_-_-------------- � 4 t -------��-` --�-----------------------------------------r------------- ------------------------------- C -----•----•----- ......_ ��/ Contractor's Name------------------------=--- .---__ `� Phone--I-----__.... 1 Installation will serve: Residence © Apartment House ❑ Commercial`❑ Trailer Court ❑ Motel ❑ Other ❑ �f Number of living units: A----- Number of bedrooms .__`_�'. Number of baths __i_---_ Lot size ____�f��-__._1�_`�U---------------___________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table `t__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ©Hardpan ❑ Previous Application Made: Yes ❑ No 0"_ New Construction: Yes E'No ❑ FHA/VA: Yes ❑ No 0' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank:f Distance from nearest well-----------------Distance from foundation--------------------Material------------------..-----.-_--------.._-_.__-_-. �.�t❑, [ No. of compartments--------------------------Size---.-----------•----------------Liquid depth--------------------------Capacity----------------------- Disposal 1 i d: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line--____---_-_----- (�� Number of lines-----------------------------------Length of e-ach line---------_-------------------.Width of french----.-.__---------.--..------------ Type of filter,material-------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest --------Distance from foundation_�'��'�.._..D'stance to nearest lot line_._"--__..__ ®� Number of pits------ ---------------Lining material-s1 _.-_---Size: Diam ter._.___ __.7.---_---_Depth-----.30___-_-___ Cesspool: Distance from nearest well-----------------Distance from foundation---.----------------Lining material----------------------_--_-_---_--_-. ❑ Size: Diameter-------------------------=------------Depth----------------------7------ -------------------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____._______-________.__.____-_____._._- ❑ Distance to nearest lot line----------------------------------------------- ---------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):--_---_-- - __e,Qy,�4 _.._f �!-_ _: .i��'_! .......�:� r` i+� � -------------------- - 4in-•-----------------------------------------------•-----=-------------- ---•---•----------- - ---- ------ ----...._- ••--- -- ---------- ----------------------------------------•------ --------------------------•---•-----------------------------------------------------------------------------�---------•---------------•---•------------ - ----------•-----------••-•-------------------------------------------- ------------------------------------------ ------- ---------- ---------------------,-------------- 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 the San Joaquin Local Health District. . L- --.---_Owner and/or Contractor (Signed{- 7— By:---- ` ( / ) ------------- ` _y_.�4 `1- M v 1'� l ( 1 � - -----Titletc ? f= -- { )--- - ? ----------------------- (Plot plan, showing size of I , location of system in relation to wells, buildings, etc., can be placed on reverse rstdej. I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------ DATE -// REVIEWEDBY -- - ---- - ---- ------------------ -- ------------------------------------- DATE------------------------------------------------------------ -PERMIT ISSUED - --------- -- DATE terati ns and/o. re mmendafions____ ______________________ i �"'_ _____ r -- 0 W �------------------------•-------....-----•---------------------- r � - --- _; � ; - r , ; F ------------------------------------------------------------ ---------------------- ------------------------------------------- -------- - - ------------------------------------------------------------------------------------------------------------------------- Date FINAL INSPECTION BY:------- -- -- [_ 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 ES-9-2M Revised 1-57 F.P.CO. P