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-4F0R"6FFICE USE: --------------------------------------------------------- � � --------- ---- ___----_- APPLICATION FOR /ANITATION PERMIT Permit " {Complete in Duplicate) _ _ G ------------ -- -- ------- TThisr 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_ L c - ON SIDF— JOB ADDRESS AND LOCATION-� t---= 0H14 �_ LQ Q~ t _L�- A-------R------ Owner's Name----------------_)__!_-------- 1/1[1�1_ �C ------------------- - -------------------------------- 4 Phone '--------------__ AddressI r'ZD�_{l + �C }�L / ------------------------- •-----------------_------••-------------------___ Contractor's Name----�-- 0�--..13_o '1-[tel_------�___-� C----- Ef?, _PC]�--------------------------- Phone..------•-----••---- - 4 --------------------------------- L Installation will serve: Residence Apartment House [-]/Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingLits: _1-_- Number of bedrooms___ Number of baths �.L__ Lot size __ > _A ________________________ Water Supply: Public system ❑ community system ❑ Private Depth to Water Table-3 t. M Character of soil to a depth of 3 feet: Sand Gravel.❑ (SandyJLoam4❑ tClay;Loam(❑�Clay L] Adobe ❑ Hardpan ❑ Previous Application Mader{1 yes, ate________ _____ _INo �w4New:=Gan`struction: Yesb [IFHA/VA: Yes E) No�— TYPE[OF INSTALLATION AND SPECIFICATIONS r.-(No septic tank or cesspool permitted if public sewer is available within i00 feet.) }T -.� Dt • e e•` ' �Se nk: t Re r nearest well ---- �nce from found�ation_ d Ir .A"-j,M� ae _ t t---- - A Sizenc.�_ __ Capa Disposal Field:V Dunce from neare-st'weli" =`-9.�:Distanc from,fouKdation_i/ ___'_--.iDistance to nearest lot Ire__ ---- Umber of lines_' -_.___��_____.___________Length of each line'2T ' "f_FWdth of trench.-.-3�__._______-�_______-_-_ hype oflfilterv<matenal____ ®___Depth of filter material____li ``Q -_Total length----------,/,-�__________________ 1P a p-r�+I�nrr� ,..-`" Dist&nce from foundation _.-_ Seepage Pit: Disfarice'to nearest well_____-___ '" '' -�-�Distancexto.,nearest lot line_________ _____ f ❑ �Nu#be_r.of pit Lining material_ Size:-Diameter! Depth---------------------------------% r r ! `A , cesspool.. _-- - stance'�from foundation-r------ -------Lining material-t--------------:--------------------. . Size: Diameter--------------------- --- -------- Depth-:-------------------------------------------------Liquid Capacity--------------------------- Privy. ----------------- -gals. 3 oo :. Distance from nearest we _ Distance to m nearer t Bulk_-____----------------------------------------Distance from nearest building----- ---- _--_ -..-.--------- - Distance - ------------ --------------------------------------------------------------- ------ - -------------------------- .F ------------------------ Remodeling and/or, repairing (desc iE�e)'__5y_ 6T�M_____�TA-R7- _ FQR ____CJ T_AN-K----�-__- �cN-------9--`-----FRoAl-------FaVN—b Ts.ON--—------ �4 r P11__i4 _ ---------- --•------------' =Q "--------------------•---•- -----------------------------------y -------------- - �' i "a ---------------------------------•--- ------ I hereby certifythat I have prepared.this application and that the work will be done in accordance with'San Joaquin County ordinances, State laws, and rules a deregulations*of the San Joaquin Local Health District. r' [Signed]--------- ----- =----------------- ------------------------------------------------ --------{Owner and/or Contractor] �- (Piot plan, showing size of lot,.lccation of system:in .relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY----- 77X-0;---------------------- ---------------------------------------------- DATE---- ------------------------- - REVIEWEDBY-------------------------------------------------------- ---------=------------------------------------------------------------ DATE---------------------- BUILD.I.NG,PERM IT.,.ISSUED---------------------------------------------------- -----------------------------------------DATE---------------:->------d - _ ,. ��.,,., _ ., Alterations and/or recommendations:- = -------------------------------- `". = `u-----------------:------------- --------•-••---- -----•------------------------------•------- ---------- 14401 4'0 Ve - ------------------------------------------------------------------------------------------------------------------------- ------------------- --•-------------------- ---------- -- ------------- --- ------- -- ------------------------------- 1 . . FINAL INSPECTI > R Date...........,r----- f�~ -------------------- --------- SAN JOAQUIN.LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED a-59 3M 3--63 r,P-CC. ti