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FOR OFFICE USE: m --------------------------------------------------------- APPLICATION FOR -SA#JITATION PERMIT Permit No. -------------------------------------- ----------- (Complete-in Duplicate) Date Issued ____. ________________________ -------------------------------- 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 Ordinance/No. 549. 1 JOB ADDRESS AND LOCATION---'- Of D7 --'�'-�-- -------h-F Q 0 ESC ,'r Lot- f--------- [� _ ��i Owner's Name---------- ----------- -------- .l i --- '-'-' --------------------------- ----- Phone------------------------------------ Address1_3 _ _ _ ,��_ _ _.........._ � �. ------- -------------•-- ------------------------- Contractor's • - -------- Contractors Name--- - ---- -•-- ---...-.`=::�=--=--=----------------- - '-'---'---'- -'----- -- -'-'-'-'--'---'-------=---..-'-'------------- Phone----•• •----• Installation will serve: Residence�Apattment House E] Commercial E] Tra�iler Court E] Motel ❑ Other L] Number of livingunits: f ----- Number of bedrooms___ Number of baths Lot size __.- ' ° .. Water Supply: Public system El.—Community system ❑� Private Et—_Depth to Water Table_:_ ft ; Character of soil to a depth of 3 ,feetw'Send ❑' Gravel ❑ 'Sandy'Loam Clay L•oam"❑ Clay Adobe ❑ Har an Previous Application Made: . (If;yes,date,.;--------,------- ) No 01-New Construction: Yes ❑ No FHA/VA: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) FrZ , Septic nk: Distance from nearest well ` -_Dista ram foundation---------W_ ,.M feral CK + p -r, ---Liquid depth _ _. •-..Capacity- ---� ----•-- No. of cam artments__-_ _ "�" Size• 1 ) Disposa Meld: Distance from nearest well-.,5..Z,).... Distance from foundation______-'____._.Distance to nearest lot I n _ ..:`' ,� ------------ • !! �1 Number of fines ------------�y-------------Length of each line__.__- -_____,�_._._.W�dth of trench._:` �_T__r_-.-._____--__._ Type of filter material---136-06k- -.-Depth of filter material____- '7______._Total length_ _._/QI0__-_-_____________- t1 . — _. � - X11 1 yi Seepage .Pit: Distance to nearest well__4Q10......Distance from foundation____I�_______ Distan a to nearest.lot;line_________________ Number of pits--:Z _ __._Lining•maierialr_1Vl K__.__ Size: Diameter _X__. - p ------------ Cesspool: 1 1 [ ►� Cess ool: Distance f3•om nearest well ----------------Distance from foundation.__..._.-._..____-.Linin, material__-.________________-____________•_._ uv ❑ Size: Diameter-- -------------`-t------- Death_.-...' -- '' ;''` Liquid Capacity_ -------- --------------- als. I 1 , Privy: Distance from 'nearest well•.-._____________________________._._._._.._...Distance from nearest building_______-._y?----_-_-__._____- ❑ Distance to nearest lot line _---._----------------------------------------------------------------------- --------------------------------- -------------------------- Remodeling and/or repairing (describe):-------._.___-___ ' I ----____--------------------------------_-------________________________......_----------------------------------------------F________ l ____________________________________________,._____ _ .- 1 - I 3 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. (Signed) •ymi� '< �,1 � u""� 9 ---------------- ------------------------------------------ ----------------------•--------------- ---------------------(Owner and/or Contractor) T By:_- ------------------------ ------------- � _`:: w,... (Tile)--'- - --------------------------- --- - ------ "T(Ploi plan, showing Size`of Itit;'locatii n of sys em in relation to wells, bulld'mgs, etc., can'be placed on revreverse sld;j.— 'J FOR DEPARTMENT USE ONLY• APPLICATION ACCEPTED BY-- t-R, DATE ' _ - I REVIEWEDBY__' ------------ --------------'--------- ----------------------------------•------------------------------------------- DATE----------------------------- BUILDING PERMIT ISSUED-------- --------------------- ......... --------------------- -------------------------------- DATE----- --------- ---- Alterations and/or recommendations:------'-'-'--'-'-'--- •-------------- ----------• ----------------------- _= ----------•- ------- ------------••-------•------------------ ------- -- -- ------- --------- ------------------ --- ---------------------•---------- ---- --- ------------- ---------------------•---•-- ----------------- ------------- PFINAL fNSP - Date � / :-G. •--------------- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ma:elton Ave. 300 West Oak Street 124 Sycamore Street 20,5 West 9th Street Stockton,California Lodi. California Manteca,California Tracy,California E.H.9 2M 1.67 Vanguard Press ° �`