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FOR OFRCI= USE: - - d- -- ------ A-_ 4 I W 9.o a -- ---- - ' -_ r,APPLICATION FOR7S,�NITATION PERMIT Permit No. --------------------------------------- ------ ---------- --- ---------------- --- --------------- (Complete in Duplicafe) -- ------------ --- .....This Permit Expires 1 Year From Date Issued --- -----------•-- 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. �j -------------------------------------- JOB ADDRESS Ay LOCATION__' - ------ Owner's Name_ - M� ---------- Phone"-------------------- --�- `. ` ------"� Address_. M1 � � = -'-------------------- Contractor's Name--- �• - ------------- Phone--------......------•-------------- Installation will serve: Residence [A"Apartment House ❑ Commercial E] Trailer Court E] Motel El Other C] Number of livin` units: __ Number of bedrooms,--- Number of baths -1----- Lot size ----------------------------------- Water Supply: Public system 2"tor system ❑ Private ❑ Depth to Water Table,40 ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ San Loam El Clay Loam ED Clay ❑ Adobe 0-"�Harcipan T Previous Application Made: {If yes,date--------------------)' No . New Construction: Yes No ❑ FHA/VA: Yes o ~ TYPE OF INSTALLATION AND SPECIFICATIONS: ¢ (No septic tank#or cesspool permitted if public sewer is available within 200 feet.),. 1 # . - I Septic T Distance from nearest well-=7777--m Distan aEon $ K -------._. Matrial-_ Ca --la---e-- -------__-- d _ _Size---•----� Liquid deP.th_-Y '-Noof compartments--_-2---------- __- __-- ----- i i i Disposal .field: Distance from nearest well____ ______Distance from foundation_�_Q'_�______--..Distance to nearest lot line_-_____- „ l !f Number of lines------ .--------�.__--Length of each I�ne._�Q_--___,i-------.- Width of trench-r�_ .-_.--------------- ----- Type of filter,material of filter material_,`f$'.____.__.____Total length___591-------------_-__-_----_ i - � R Seepage Pit: Distance to nearest well---__`--:.___---DistanC-, .om foundationIi�-------------Distan�e to nearest lot line__:__ -.__ , t- ,' - Depth---- �r�-------- f Number of pits--,--/ material____+,_C_Q ____Size: Diameter---- .__ __ Cesspool: Distance from nearest well----------------- from foundation____________________Lining material_._.__....___..._.__...____.__.______. I ❑ Size: Diameter-- i-=-------- -------- ---------------Depth------------------I---------------------------------Liquid_Capacity---------..-----------------gals. `s I _.-Distance from nearest buildin Distance to nearest well g 1 Priv Distance from n r - y' ❑ `rest lot line-- --------------------------------------- -- -----==------------------------------------- ---------------------------------------------- Remodeling ---------Remodeling and/or repairing (describe):---------------------------- --------------------------- --------------------------------------- ------------------------------------------------------- 1''•'' ff --------------- --------------------------------------------------------------------------- ------------------------------------'_-,._'F-------_____----____-_----.____------_-__.______.__._____._. ___._____._.________________ _________________ ---------- --------------- ______________________ ------------- ------ '__._ __------------------------------------ ._--;-______--._______.._______________________.._________.____.__._____________.______._..-_____-..__..______.._.__ ! hereby certify that I v prepared this appl Ion ant! that the ork will be done in accordance with San Joaquin County ordinances, State laws,'.and es ti regulations the an Joaqui oral Health District. (Signed) + J ------- ----.(Owner and/or Contractor) -------------------- ------ ----------------i-----------------------Title (Plot plan, showing sizelof fat, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 7 APPLICATION ACCEPTS© BY-------- DATE f -t�� -------------------------------- ------------------------ REVIEWED BY------------------- 1----------------------- ---- ------------------------------------------------------- DATE - BUILDING PERMIT ISSUED--------------------------------------------------------------- DATE ------------------------ ` ._ _.�. w _ .:_.w.. --. f Alterations and/or recoMmendations----- --------- -------. 1. ----------------------------------------------•----------------- ----------------------- ------------------------- 1 ------------ " i -------------__-- ------- ------•---------------------------------- ------------------------- ------------ ------------- --------------- �.QDate. •��[�, ---------- --------------------- FINAL INSPECTION BY:...._- -..___A�__...._..__ . 4--- SAN JOAQWN•L CAL HEALTH DISTRICT 1601 E.Haxelfon Ave. •{ a 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C 0.