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APPLICATION FOR,.._ANITATION PERMIT Permit No. (Complete in Duplicate) t,..__ Date Issued .... ............... V Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. `� is application is made in compliance with County Ordinance No..549. JOB ADDRESS AND LOCATION______��_ 4A _� _________________•___ _ - ------------------------------------------------------------------------- ----------- 1� - --------------- Name � •'---- -------------------------------------- -------------------------------------------- Phone- Owner's. -----------.s�,7.--- -------•------------------------------------- -- - Address---------------- � - ... Contractor's Name--7i:) ---------------------------------------------------------------------------- - -- Phone---------------------------- j Installation will serve: Residence 5y Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___�_-. Number of bedrooms _2,,,._ Number of baths ---I--- Lot size ___-�O__*J.tt-------------------------------- Wafer Supply: Public system VICommunity system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ i Previous Application Made: Yes ❑ No 91 New Construction: 'Yes V o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: Distance from nearest well-----------------Distance from foundation------------------ - Material---------_____--____---__-____-_____._____-__-_-. No. of compartments------------ - ---------Size---------- --------------------Liquid depth--------------------------Capacity...-------------------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------______- Number of lines---------------;-------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material----- ------------------Depth of filter material-----------------------Total length------------------------------------------ Seepag it: Distance to nearest well.__-Q._---____-_-Distance from foundation____ 8 ....Distance to nearest lot line__ 7r'___ e Number of pits----l_______________Lining material_---------Size: Diameter--------- ------------Depth----- ________________ Cesspool: Distance from nearest well-______----____Distance from foundation---------------------Lining material____.__-_--_______.____._---__---_._ ! /"� ❑ Size: Diameter---------------- `------------------Depth-----------•---------------------- -----------------Liquid Capacity------------------------- I rivy: Distance from nearest well _____---------- ---------------------------------Distance from nearest building.-________.__.__________--•-_--.--._--... ❑ Distance to nearestilot line-------- ----------------------------------- -------------------- ----- -------------------------•------------------------------------ Remodeling and/or repairing (describe):--- --->-. ------L` - �' .--•- ---- ----- ---___•-••- I --------------------------------------•--------••---------------------•------------------------------------------------------------------------------------------------------•------------------------------------------------ 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) By:-------- --------------------------•--- -------......................................(Ti+le) -- ------------------------------------ (Plot plan, showin si of lot, loc ion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --- ----- - -- -- -------------------------------------------------------- DATE_. --- -- ---------------------- REVIEWEDBY--------------------------------- ---- - - - --- ------------------- -----------------------------------. DATE-6--- - --- BUILDING PERMIT ISSUED----------- ----- -----------------------•---------= ---------------------- DATE.------------------------------------:------- --------------- Alterafions and/or recommendations:------------------------------------------------- .... ---------•----•-•----•-••----------------.-------•-•-•--------....-•-------------------------- - - - - - - = ------------------------------------------------------------------------------- ------------------------------------- --------------------------------------------------------------------------------- -----------------..-..-----------------..-------..-------------------------------------------- ------------------------------------------------- ------------------- ------------------------- ------------ ------------- -------------------------------------------------•----------------------------------------------- FINAL INSPECTION BY:...-: ..� ------ Date.------ --- ..._'_ s _�._.- ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street' 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, Californ16 Manteca, California Tracy, California ES-9-2M ; Revised W-2100