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APPLICATION FOR,-._ANITATION PERMIT Permit No. ....`?.=�__ - .. V (Complete in Duplicated r Date Issued pplica*ion is hereby made to-h-e`San Joaquin Local Health District for a permit to construct and instal{the work herein described. pis application is made in compliance ZI County Ordinance No. 549. JOB ADDRESS AND LOCATION-:rZ =--- f N --- _ _ o - _ Phone Owners - . . _ •-��; �1_ FF Address.......!Z' Z- --- ----------------------------------------- ---------------------------------------------------------------- 7- Y Contractor's Name---- ------------ ----------------------------------- ----------------- -------- Phoned -{ -------------------------------------------- - Installation will serve: 'Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [❑ Number of living units: __ "_ Number of bedrooms_2__ Number of baths ___i__ Lot size __gQ--- ___1_Jb__________________________"-__ Water Supply: Public.systemi 2'0,c6mm6nity sysfem ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 09-`11'ardpan ❑ Previous Application Mader Yes ❑ No New Construction: Yes &�,/No ❑ t TYPE OF INSTALLATION AND SPECIFICATIONS: (No sepfic;tonk or cesspool permitted if public sewer is available within 200 feetfi _ . .. y - - Septic Tank: Distance from-nearest well'__,.- --_-- Distance from foundation-------------------.Material _____._--____________________________-________- No. of compartmems--------------------------- -Size--------------------------------Liquid depth--------=-----------------Capacity-----------,----------- Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line------------------ N Number of lines----------- ---------------------Length of each line-------------_----------------Width of french-------------------------------- Type of filter.material_,________ ___-____._.__Depth of filter material----------------------- length-_-___________________._______------__._ Seepage it: Distance to nearest well=:______ _().____-__Distance from foundation___--._.. _�,0ce to nearest 12t l ---------------- 36, Number of pits----:1---------------Lining material__ "5.-+.._Size: Diame er"__ __.._...__..___.Depth--,-1✓S_-- ------.--------- Cesspool: Distance from nearest well--=--------------Distance from foundation---.____....______.:Lining material______.______ _____._________-_-_____. Size: Diameter-`--------------------------- ----De th______________________-- Liquid Capacity-.-. gals. ❑ P ------------- q p y-.-.----- ----- - 9 k, Privy:: Disfence from nearesf well-__________________-_:_ -------------------------Distance from nearest building------------------------------------------ -:'Distance ---------- ❑ -:'Distance fo-nearest lot line'--`----------=----------------------------------•--.----- ----...._ ------------------------------------------- Remodelin an /or'repair'n (describe)=--- -------- - ------- ----- //////{{{{{{�� QQQQQQ -------------- r = ----F-------..`�--- --- _____________________________________________________________---------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordin an ces, laws,r.end rules and regulations_of the.San Joaquin Local Health District. (Signed--•--- ----------- ---------------- ------ -------------------•- ----------------------------------------------------- -----------(Owner and/or Contractor) By:--_-------------i--- - ------ --------------------------------------------------------------------------(Title)- - ------------------------------------ (Plot plan, showing sze f o location of sfem in relation to wells, buildings, etc., can be placed on erse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_7.t._Van ------ DATE-----�------------------------------------------------- REVIEWED BY - - QAT --- --�--- BUILDING PERMIT ISSUED--------- �� ---------- DATE--- -- - --- � ----------------------------------- Al+era+ions and/or recommendations:__________________ __ . ------------ __ ____________________________________________________________________________ ..______._______._________ ------------------ ------------------------- = = - - = -------------------------- - --- --- ------------------------------- ------• ------ ------------------------------------------------------------------------------=---------------•----------------------- r ' FINAL INSPECTION BY:--_------------ --- Date.-------_ -_- �' 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 ES-9-2M ; • Revised W-2100