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3 APPLICATION FOR . ANITATION PERMIT Permit No. :�: �3.__ ... (Complete in Duplicate) 3 Date issued _--- 'l Applic&ion 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.:4_z 1. •_---� Owner's Name--- '�- �n1 ti -- - --------------------------------------------- Phone--- - -4 -- - Address k_.'t --------------------- ------ --•-----------••-----------------•--------------- Contractor's Name...._ _ F Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [❑ Other ❑ Number of living units: _-_I---- Number of bedrooms �,-- Number of baths ---(---- Lot size Water Supply: Public system [K1164 ommunity system ❑ Private ❑ Depth to Water Table --------- ft. Character of soil to a depth of 3 feet: Sand ❑. Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2 Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes g-"No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: + (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from _. -__-.Maerial _--No. of compartments--___""-"-?3__________""Size�� f ___""" - 1._ ""_1 " Li Liquid de th--. ---4 . Capacity--- 5- &._,a---------Disposal a Field: Distance from nearest well-----------------Distance`from foundation-_----.._---.--._-.Distance to nearest lot line:__""-__"" ""_ 1 Number of lines------- ----------------------------Length of each line---------------------------.-.Width of trench Type of filter material------------------- ------Depth of filter material-----------------------Total length------- Seepage Pitt Distance to nearesti well..-_ ----- •sta ro dation-------Z Q_---- Distance to nearest lot line___1_( r�__• '� �y Number of pits---- --------------�_Lir:ing ma al-- --- ize: Diameter------3 I Depth_..- "Q -� 3 Cesspool: Distance from nearest welL__"":,,-__"--_"Dis ante Y ndation--_�^�_____.___-_.Lining material--.-.__-_�_-_`=/_""-_"_- ' -- ❑ Size: Diameter-- : -------------------Depth-----------------t'------- - Liquid Capacity----------------- gals. Privy: Distance from nearest well -- from nearesr building--_____.____"----------------------------- El Distance to nearest lot line--------------£:-__ Remodeling and/or repairing (descr'ileJ: \ ^'!+` g , -------------------------------------------------------------•-----------•------------ --- ---------------------------------•--•----------- ------------------•------------------------------- 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)------ �f--.&' ---_•._----------I � r I ----------------------------------------------------- _ caner and/or Contractor) By:------------A�size i (Title)_ --------------------------- (Plot plan, showin , lot, location system in relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY' APPLICATION ACCEPTED BY ----- DATE--------- -- - ------------------------------- a------ REVIEWED BY--------------------------------------------------- ------------------- ------------------------- --------------- -- DATE---------- BUILDING PERMIT ISSUED---------------_-----_------- ____ -------�-----�---•-=-----------------"---------=-------- DATE---------- ------- ------ Alterations and/or recommendafions------------------__"" ._ --------- ----------- -------•------- -- ---- ------------- --- - :- ------- ,:-- - ------------------------------..---------------------------------------=- ------ i --------------------- , -------------------------------------------------iI•__---------------------- FINAL INSPECTION BY_______________________ "-"-_-"".- - ---------------- Date.--------- ------------- ----- -----------------------------------------•- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American S+reef 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised W-2100