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t APPLICATION .-S FORANITATION PERMIT Permit No. rJ_ _ "..... ___ (Complete in Duplicate] 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. I � r T f/ � �- -YL� ---•---------- -------------------------------- JOB ADDRESS AND LOCA ---------- -�" �:=- Owner's Name--------------------- - ----- ----- - --- ---------- ----------------- - ------------- -------:---------- - Phone--------------------- Address---------------------------- -•- --- -- - -------------------------------------------------------- ---------------------------------•-- Contractor`s Name--------- -- ---- Phone----------------------------------- Installation ---- -- - - - Installation will serve: R idents 0Apartment House ❑ Commercial ❑ Trailer Court )l Motel ❑ Other ❑ Number of living units: -_1_._ Number of bedrooms -__2-Number of baths __/_-_ Lot size _ lD_ _._. a------------------------ Water Supply: Public system orlCommunity system ❑ Private ❑ Depth to Water Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy loam ❑ Clay Loam ❑ Clay ❑ Adobe [off, 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.) Septic Tarik: Distance from nearest.well-----------------Distance from',foundation------------.------.Material."-_""""______----.--."-----__"_-..-____--_--- ❑ ,,,�go. of compartments--------- Size" f-----------I------------Liquid depth-------------------------Capacity-----------��t--- t t' ". i Distance from nearest well_ .Distance from'foundation-----/l?___------Distance to nearest lot lireR Number of lines_. '_;`__ ,.__ _____-Length of each line-1-d"-'_ _�-___ Width of frenc- h renc �. ' Total length_:_ _ - Type of filter material_-- =---Depth of filtermat.erial__- ------"- --- Seepage Pit: Distance to nearest well______________ ____�Distance from foundation__"-____.-_.______".Distance to nearest lot line----------------- ❑ Number of pits-------"------------- Lining material---------------I--------Size: Diameter-----------------------Depth--------------------------------- mI Cesspool: Distance fronearest well----------------- Distance from foundation_ _ _ _ -_.______ ___----.Lining material".____.___ _"_____________ ____-___ 171 Size: DiametV ------ ----Depth---------------------------------------------------Liquid Capacity..--------------------------gals. l - Privy: Distance to nearest a nearest well_-""_."__________________--__--------------`---Distance from nearest ;,wilding----------------------------------.------- irom r ❑ lot line----------- - --, a Remodeling and/or repairing (describe) ' -------------- ------------ ti IN "__ ------------------------------------------------------------- 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 Lo'al Health District,. (Signed)--- t -- = -----------y---------------------------- (Owner and/or Contractor) �Y� --------------(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system,�in relation f; wells. buildings, etc., can be placed on reverse side). !. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ----------------- ---. ) DATE-------- REVIhW1 D BY - = # ---------------------------- QA7E 1 -- . % BUILDING PERMIT ISSUED----------------------------- s DATE Alterations and/or recommendations:-------=- ------- -`��h'-��------------------------- --------------------- --------- ------------------ •------- ---------------•------------------•------------------------ --------------,------------------------ f I--------------------------------------------------------------------•-----------------------------------•----------------- -- FINAL INSPECTION BY:. - Date-----------.f l -.. --------------------------------------- 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 LS-9-2M , Revised 1.57 F.P.CO.