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FOR OFFICE USE: ----------------------------------------------------- -- ------------------------------------- ------------------- APPLICATION FOR*SANIWION PERMIT Permit No. ---- (Complete in Duplicate) ___________________ 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 instal(the work herein described. This application i de in compli nc with C my Ordinance No. 549. JOB AD DRE S AND LOCATION_`- ' _f ,r _._____1 --- �G'�/ 111-- �� Owner's Name------ --------------- Phone--------------------•--------- / - - = ------------------- •-•-•-----------------------------------------------�------------•-• ------------------------------- Address ----------- Contractor's Name----- yr ----�------------------------------- -------------------------------------------- Phone---•----•-•------------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ - Number of bedrooms.9---Number of baths _0__ Lot size ------------------------------- Water Supply: Public system ❑ Community system 2"'Private ❑ Depth to Water Table PQ- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel Ugl"'S`andy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: {If yes,date.-. ---- -- ........I No ®/'New Construction: Yes �o ❑ FHA'/VA: Yes 24-1"TNlo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: > (No septic tank or cesspool permitted if public sewer is available within 200 feet:) Septic Tank: Distance from nearest --- '--^__..._Distance from foo,undation-fa---------Material-f.! " �� --- --- -------- Lyf No. of compartments_ __ __________________Sizeed� i � __`�iquid depth--._��.__..__._.___Capacity./2-A-1r`V_.___ Disposal Field: Distance from neare wefi___!�- -----Distance from foundation-/`e.---- _.Distance to nearest lot line_ -------- Number of lines----- --------a__. _ Length of each line___ _ ______...Width of trench___. ___ -------- Type _____ Type of filter material` 1Depth of filter material___ __--_.Total length- �- -------- - 4 Seepage Pit: Distance to nearest well----- a-_--.---Distance from fo ndation---9-V----_-_.Distance to nearest lot line__.__._--_-.- Number of pits--___/.............Lining material- � .. Size: Diameter__-PX--"y.-__.---Depth.4,7_ 1 Cesspool: Distance from nearest weft-----------------Distance from foundation--------------------Lining material--.-...-.___-_.____.___.___----..._. ❑ Size: Diameter--------------------------------------Depth.---------- ----- --------------------------------.-Liquid Capacity----------------- -- -..---gals. Privy: Distance from nearest wel!-----------------------------------.-------------Distance from nearest building-----..-.------------_-_-----.--_---.-.-. ❑ Distance to nearest lot line------ ------------------ - - - ----------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe): �I-- -/�l �: 4 --•-- - -- ---- f P ------fry 'A ---• - ----- - - -- ----- --- --- �� `T�------01 --~/ �----- . ---------------------------------------------------------------- --------------------------------------------- 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) ---------------- -------- --- Contractor) (Title)---- (Plot plan, showing size of lot, location of system in relation ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ --------------------------- DATE---- 4 REVIEWEDBY---- --- ---- --------------------- - - ---- ------- --------- -- -------- ----------------------------------- -- - DATE-------- -- ------ N.•------------------------- --- - -- 4 BUILDING PERMIT ISSUED---------------------------------------------------------- ------------------------------------------- DATE---------------------------------------------- -------------- Alterations and/or recommendations-------- ------ - - ---------------------------------------------------------------------------- -•---------------•-----•-------•------------------------------- ------------------•----------------- ------ ------------------------ ----------------------------- - -----------------------------------------------I-------------------------------------------- ------ E -------------------------------- - --------------------------------------------- ----------------------------- --------------•----------------------------- -------------- ----------------------------- FINAL INSPECTION BY:_._ ivr. ,__U�_._ r�................. Date--....._. _. .,� -��- -------------------------------------------- ! Y _ -SAN JOAQUIN LOCAL HEALTH DISTRICT 1601,E.Hazelton Ave. 300 West Oak Street t. 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California r ; Manteca,California Tracy,California F.P.C 0- r l