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FOR OFFICE USE: -----------------------------_-_--- APPLICATION .....ASANITATION PERMIT Permit No. ......_ s - ------- - ---------------------------------------- (Complete in Duplicate) Data Issued 13 ------_-----____________________-------------------_ This Permit Expires 1 Year From 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 Ordi once No. 549. � e - JOB ADDRESS AND LOCATION -------------------------------------------=------------------=------------ ------------------------- Owner's Name------ ------ ----------- -- Phone-------------------------------- Address--------------�a---------------------------- .--•-•----•---------------- -- •---------------------------------------------....---------------••------------------•----=---------- Contractor's Name__ .______. - Phone_________________________ ---------------------------------------------------------------------------------------- --------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer 66ort K Motel ❑ Other ❑ r � Number of living units: _f umber of bedrooms __-L__ Number of baths—.-.-.Lot size -------�-p�_ (...... . r1- ------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand 171 ravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe El--Hardpan ❑ Previous Application Made: (If yes,date.___ / No ❑ New Construction: Yes ❑ No [j�, �HA/VA: Yes E] No ❑ TYPE OF INSTALLATION AND SPEC �ATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance' from nearest well__K---------k__Distance from foundation___________________ Material---------------------------------------------- 0 f7C --.___________..__:_____._________-..----._-❑PjG _;7No. of compartments-. --------- Size---------------------------- ---Liquid depth---------------- ---------Capacity----------------------- Disposal Field: ° Distance from nearest well_________________Distance from foundation---------------------Distance to nearest lot line_______________-_ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of.filter material----•--------------------Depth of filter material--------------------------------------- length----------------_-_•--------------..------ Seepage Pif: Distance to nearest well------------_---------Distance from foundation---._-.___....___.Distance to nearest lot line_____.___________ ❑ p ------Lining material------------ Size: Diameter-------------------- Depth--------------------------------- Cesspool: ---------------- I_ l�Iumber of its---------------- - ----- --- ---------- ---. � ❑ stance from foundation---_________________Lining material__----________-__._.-_--_____._______. a Cesspool: Size:Diameter nearest well-------------- -p.ePth---------- ----- ---=,-------------Liquid Capacity----------------------------gals. r Privy: Distance from nearest well--------------------- --------------------- ---Oisfance Oisfance from nearest building------------------------------------- [] Distance to nearest lot line.- ------------- - i - 1 � � � �:. • rot Remodeling and/or repairing �___________. s 1 .a_ - ._.�, ,1cr� �-�2----------- ------ ---------- ----------------------------------^_---------- ---------------------- - ----- -- ----- ------ 4-------•I -----`�-t-------------- -- ---- p---`�� - ---- - --------------------- ----------------------------------------- I hereby certify that I have prepared this application and that the work will be'd no a in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the'San Joaquin;Local Health IDistritf. (Signe d)�� `------ ---- ---------------------- `-=------------------------------.(Owner and/or Contractor) --------------------------------- -----=---------------------------------------- Title (Plot plan, showing size of lot, location o f`system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.....- -------- ` '� - =--------------------------------------- DATE c ----- _/_/ ----- REVI EWED BY--------------------------------------------- - ---- -- -- ---------=----------------------------- DATE PERMIT ISSUED----------------------- ----- ---- -------- ---- ------------ DATE---------------------------------------------------- Alterations and/or recommendations:.____ ......7— _____ - - -jam ------ ..l'`-a-r ----------------- Jc►-n= _��lrl ------- - - �` / p . v ----------- . .. � `` �' -� `""''4•`Lt. - ----- --------- ---------------------------------------------------=------------ -------------- FINAL ---- ------FINAL INSPECTION BY:_�� ..� �•'"- Dae ------------------------------------ --------- SAN JOAQUINIOCAL HEALTH''�DISTRICT: 1601 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street i Stockton,California Lodi, California M ntota,California Tracy,California ES 9 REVISED S-59 3M 3-'63 F.P.CO. fi.