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FOR OFFICE USE: _________ y ' ff" APPLICATION FOR aSANRATION PERMIT Permit No. --- ---��--- ---- --------------------- --- (Complete in Duplicate] Date Issued _///� • '�' ----------------------------------------- This Permit Expires 1 Year From 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. JOB ADDRESS AND O�ATION.."��,O--o--------- -- ---�.---'�-------------- - - ------------------------------------ --411 { Owner s Name----- -- ---- Phone------------------------------------ Owner's JJ ---•------ Address------•- &j= { Confrac#or's Name --- -------4-----------------------------•-------------- ----•--•-------------------- Phone---•--•------------------------•--- -- - -- - - ❑ Motel Other Installation will serve: Residence K Apartment House ❑ `Commercial Trailer Court ❑ ❑ ❑ Number of living units: _f-___ Number of bedrooms __/_ Number of baths -_/- Lot size: -,___!S_-----------------.-----•--------------------------- Water Supply- Public system ❑ Community system ❑ Private K Depth to Water Table I0-ft. % Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑'1 Aclobex Hardpan ❑ Previous Application Made- (If yes,date--------------------) No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: C(No septic tank or cesspool permitted if public sewer is available within 200 feet.) rl �r l i anki Distance from nearest well_________________Distance from foundation-------------------Material._._ ------------- --------------------- ------- No. of compartments--------------------------Size Liquid depth- Capacity... Disposal Field: Distance from'nearest well- D-._.._Distance from foundation____! d-!"--.Qistance to nearest lot line____��._______. 1 Length of each-line___'- Q---.�y----Width of.trench--------- ______------------r--- Number of lines---------- � -- t _Total len th-----------------=------ ------ Type of filter matena3_}_�,_ - __Depth of filter niatenal_.:��"-.____--_ g Seepage Pit: Distance to nearest well___-_- -_____....__Distance from founds#iori__ _______________Distance to nearest lot line----______.__.._ ❑ --- sial-------`----------------Size: Diameter---------- ------------Depth_.. ----------------------------- Number Cess ool: Distance well- Lining material from foundation'!--_-_.--____.Lining material____________________________________. p ------ a1s. '} ❑ Size: Diameter"_"----------------------- --------Depth------------ ------------ --------- ---- ------Liquid Capacity ------------------------- F1 - 9 W 4 Privy: Distance from nearest welll- -------------__.__-'------------------------Distance• from nearest building----------------------------+-----.- --. ` ❑ Disfance to nearest lot line------------------- ---------=------------------------------------- -------------------------------I------I--- ,r' Remodeling and/or repairing (describe}-------------------------- ---------------•---------------------------- ---------------•----------------------------------------------•------------------------------------------------------------------ ► -"------------•----------•-------•-------------------------------- - -- ----- --------{ { ------------------------------------------------------------------------ ........................------------- - -------- f l here ertify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance , St a laws, a d r and regulations gulations of the San Joaquin Local Health District, f and/or Contractor) {Signed]-_--_ _ { caner d/o or]- g ---------------- ---- --- { . Title]__ - - -- .- - ------------•-- Plot plan, showing size of lot, location of system in relation to wel buildings, etc., can be placed on reverse side). i l FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------- ----------------- ----------------------------------------------------- REVIEWED -----------------"---------------------------------REVIEWED BY---------------------------------- - --------- ---------------------------------------------------- --- -----------• DATE------------------------------------------------------------ BUILDING PERMIT ISSUED-------------- ------------ -- - --- DATE Alterations and/or recommend s+fans---------------------------------------------- ------------- -- --------------- --------- ----•-•-----------• ------------------------------------------------ 'f -----•----------------------- ---------------------------------------------.------------- ------------------- --- -------------- ------------------------------ --- I r -----.. ------ ------------------- ---------------------------------------" t ------ ------------------------------ 1 - -------------------------- -------------------------------------------- t _ �. ` FINAL INSPECTION BY:... -f'_:r- SAN _._ -- Date_..L� -----' �„ JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. est Oak Street 124 Sycamore Street 205 West 9th Street p.. Stockton,California Lodi,California •- ,Manteca,California Tracy,California 3 ES 9 REVISED 6.59 3M 3-'63 F.P.CD, 'S 1