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FOR OFFICE USE: , - - -- ------- ------ - --- - - / ------- --- APPLICATION FOR`;'ANITATION PERMITPermit No. __...1..7.__!.W - -------------------- ----------------_-------------------- (Complete,in Duplicate) `------------- This Permit Expires 7:IYear 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 applicafion is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION..#_1__Z ____ _� ----------------------------------------------- r __ __ ___ _ _-______--..___.____-_--__-____-_..___________-_.____ Owner's Name__._- "-- '------- kr Phone.----------•-----------•----- Address.-----------•tr 3.1 ---- ? ]__�--- - " --- ----------------- -------- Contractor's Name__. -I --------------------------------------------------- Phone......•-------------------- Installation will serve: Residence E�-partment House ❑ Commercial ❑ Trailer -Court ❑ Motel ❑ Other [❑ Number of living units: __.t___ Number of bedrooms ____Z_ Number of baths �------ Lot size -_�S" _____"-�-10 a Water Supply: Public:system ommunity system ❑ Private ❑ Depth to Water Table 4 _ ft Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe El—ftardpan ❑ Previous Application Made: (If yes,date---_----------------) No-Hj�New Construction: Yes EB-71% ❑ FHA/VA: Yes ❑ No ❑--- TYPE OF INSTALLATION AND SPECIFICATIONS: I `s (No.septic tank or cesspool permitted if.,public sewer is aivailable within 200 feet.)- Septic Tank: Distance from nearest wefl_____ ________Distance from foundation__la_____F----Material_____ No. of compartments-�----------------Size----_X��-J - -----Liquid dep#h---- ------------- 0 Disposal Field: Distance from nearest well--- ---------- from foundation_A0..____ _-__-Distance to nearest lot line__GS`._.__... [�]f Number .of lines___-1___________�-'_'" _-Length'of-each line`"__�_4___�_-__"_- ----"Width of trench-4 4--`___- "_"--______--- Type.of filter material_r�d_4�_____Depth. of filter material-_/ _4__-___.__.Total length___ �_.�"_":.______________-__ __ Seepage Pi Distance to nearest well-_____.___�'__-_-Distance from foundation__-V.�_•:_....Distance to nearest lot line��___... Number of its.-f""'_______._____Linin material. 41. _c./�'__ Size. Diameter______________ p g Depth_._. c3'---------------- Cesspool: Distance from nearest well_____ __________Distance from foundation------------------_Lining material--------------------------_____.""__ J ❑ Size: Diameter --------- ------------ ------Depth-JI---------------------------------- ----------Liquid Capacity- --------------------------gals. i Privy: Distance from nearest well--------------_______ _ ________.________Distance from nearest building_________"___._____._ ❑ Distance to nearestElot line -'-- -----------:------------------- --------------------------------------- ------------------------------- Remodeling and/or repairing (describe)-------------------------------------- ". ---------------------------------- ----------------------- _ I ____________________________________________________ k _________ __________________________________________________________________________________________ _______"_"____-___________.._-__"________________-___ _--------------------------------- _____------------------------------- __ __ ___________...---_________.__________-___________-______---______________.----------------------------------------------------_._.._____"___. I hereby certify that I have prepared this application and thaf(fhe work will be done in accordance with San Joaquin County P ordinances, State laws, and rules and regulations of the San.Joa.quin Local Health District. (Signed) ----- ------- ------- .... -- Il------ ------ -------------------------------------------------------- ----.""'(Owner and/or Contractor) BY: -----,-- -- --------------Il ------------(Title)---------- --- ----------------- ------- ------- ...... (Plot plan, showing size o , location of system in relafion to wells, buildings, etc., can be placed.on reverse side). FOR DEPARTMENT USE ONLY l APPLICATION ACCEPTED BY _Fl --- -- -----------------------!-------------------------------------- DATE- = �" ' REVIEWED BY - it I .,I -------------------------------- DATE------------------------ BUILDING PERMIT ISSUED = = DATE_ �� - Alterations and/or recommendations: _ 7 _ �� . -------------------------------•-------------------•---------- = � ------------------------------- -, - ---------- ---------------A------------//= - -- �j ---------------------------------------- ------------------- ---- ----- i- = ----- -------------- ---------------------------------------------. ----=-------- Date.....-�l FINAL INSPECTION BY:-----" `` ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S-59 3M 3-'63 F.P.Co.