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FOR OFFICE USE: �z " ' '�n 7 y y,� �y6 --------------------------- ------------------ --------- APPLICATION,` FOR— ANITATION PERMIT Permit No. ._,.-5---.....� -- ---------------------- - ----------------------------- .Complete in Duplicate) ------------- This Permit Expires 1 Year From Date Issued Date Issued ___.--A--- _-6 3 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. r JOB ADDRESS AND LOCATION:_: _ --- _.._... - �_ - _______ _ ____ -- " ------------ ---------------_-.... f ' '� ----------- Owner's Name .._._a --------------------------------------------- -------------------------------------------- Phone------------------------------------ Address................... ---- Contractor's Name --------------------------_------•------------------------------------------------------------------------------ Phone........--_.............----------- Installation will serve: Residence [a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �e Number of living units: -1---- Number of bedrooms _3____ Number of baths �_Y Lot size _`�'�t X470 Water Supply: Public system ❑ Community system ❑ Private [�] Depth TO Water-Table 0__q_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam R] Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Of yes,date____________________J No ® New Construction: Yes-BNo ❑ FHA/VA: Yes ❑ 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__r?a------Dis{ane from foundation.__..-14.'__-_.Material--- No. of compartments_____ -- - Size x' R.�___��- ---Liquid depth_____(________________Capacity.-Ye �'_____- Disposal Field: Distance from nearest well_0-la_---------Distance from foundation:__1d'________-Distance to nearest lot iine_ff`'..._...... ® Number of lines_._..�_____________________ Length of each line------ ____---------- of trench------gh-1 ___.___...._..... Type of filter materia_ --Depth of filter material.../--_``_________Total length-__.' -Q_!_________________________ Seepage Pit: Distance to nearest well------------ _______Distance from foundation--------------------Distance to nearest lot line_______._______-_ ❑ Number of pits----------------------Lining material----------.-------- -Size: Diameter------------------------Depth----_----..-----.----..--_------- - L Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material---------..---------.........___.____ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------go Privy: Distance from nearest well-----------------------------------_-------------Distance from nearest building___________.-__------___-_________--____. ❑ Distance to nearest lot line---------------------------------------------------------------------------•--•----.--- Remodelingand/or repairing (describe):----------------------------•-------- -- ......... ---------------------------------------------•---- --••----------------------------------- ------•-----•--------------------------------------------------..-------------------------------•-------------------------------------------------------------------------..---------------_--------•-----•---------------- 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)----- ----------------------------------- ------- ------(Owner and/or Contractor) -------------------_(Title)' -------_"--- .:.�.�a-�,�f- ----- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .C. ------------------------------------------------------------ DATE.47-7-' r --------•----------------------- REVIEWEDBY----------------------------------•---------------------------- -----------------._...---------------------------------•---- DATE------------ ---------------------------------•--- BUILDING PERMIT ISSUED--------------------------------------------------------------—-----------------------------------... DATE---------- --------------------------------- Alterationsand/or recommendations:-:------------------------ --------------------------------••.--------------------------------•--•-------------•---••--•------..........---------------------- Oe! FINAL INSPECTION BY: - -- -- - - - `�"104-------------------- Date---�� r/y--4�--------------------------------- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California ; Manteca,California Tracy,Coilfornia ES 9 REVISED 8.59 ZM 5-62 ATLAS At - ws