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FOR OFFICE USE: --------------------------------------------------------- { APPLICATION FO"AITATION PERMIT Permit No. (Complete in Duplicate) µ 7" 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 install the work herein described. This application is made in compliance with County Ordinance No. 549. -41L)! 00S-S.-O—OX 43f sr E. G,a.Gr�•-�Y.�/� �� . I ------------••------------------ ,� s. JOB ADDRESS AND LOCATION_ _ .- �.X-----------�-------= -------------- •---'----------------------- -- ------------- - IOwner's Name------. ---------4A11✓7.111—1--------------------------------------•----- ------------ - ----------------------------- -------------- Phone------------------------------------ E r 1k - Address------------•--- __._ _._....! -------------•---------------------' '`---------------------------------_---------------_------------••-------------•--- Contractor's Name_ -------------------------------------------------------------------------------------------------------------•-----------•--- Phone----------------------------------- Installation will serve: Residence El Apartment House ❑ Commercial ❑ Trailer Court '❑ Motel ❑ Other ❑ Number of living units: -__.__ Number of bedrooms ------ - Number of baths -------- Lot size _____________________________________________________-_--_ l Water Supply: Public.system ❑ Community 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 ❑ Previous Application Made: (If yes,date__________________-) No ❑ New Construction-. Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: (No-septic-tank-6r-cesspooFpermittediif�public sewer-is available-within-200=feet.) - Septic Tank: Distance from nearest wel{_ _____________Distance from foundation-------------------Material_____---_--_----______-_________--_______-_-. ❑ No. of compartments------ r- ----------------Size---------------------------- -_Liquid depth------------------------- Capacity-----------•-- -------- Disposal Field: Distance from nearest weILI---------------Distance from foundation-------------------_Distance to nearest lot line___________._.__. � k ❑ Number of lines----------------------------------Length of each line------------------------------Width of trench----------------------------------- (�1 l Type of filter material_______ ____________Depth of filter material----------------------- length------.---------------------.__-____-__---- a Seepage Pit: Distance to nearest well�` ;_��_ Distance from foundation_j°--_________Distance to nearest lot line 2.O--____-_ ;0 {dumber of pits--- ----------------Lining material:��_r*`�-----.Size: Diameter._�c�--�-----------Deptn2--�----------------------- I cesspool: Distance from nearest well_---__---' _Distance from foundation-------------------_Lining material_.-.-___.___---_-.-.___.-_____._____. Li uid Ca acit ______ als. I Privy❑: Distance from nearest well--- ------------=�•__r�-- •-------. �--�----- - --------- - --------- - - �l A Y- -------------- - g Size: D�ameter------------------------------- ----De th s � .-Dista`nce from nearest building---------________________-____-_-_------ ❑ Distance to nearest lot line......--------- --- '--;------------------------- -------------- ----------------------------------- -- ----------------------- Remodeling and/or repairing (describe):---- '►. i ,�'*-_!- ls ' h-rr -------------------------------------------------------- / :. F -------------------------------------------______-________.---------------------------------------------------------------.-----------------------------.---------------------------------------------------------------__--_ __________________________---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------___________ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Statws, and rules and regulations of the San Joaquin Local Health District. - ► ------- ------------------ --------- ---------------------- ----------------------------------(Owner and/or Contractor) (Signed)---:----- (Plot 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---,A ------------------ -------------------------- DATE/-Y'3-1 ---------------------------------------- ' REVIEWED BY------------------------- ----------------------------------------------------- ---------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations:----------------_------ --------- -•---- ------- --------------------------------------•----------•--•-----••----------------------------------------------- •----------------------- ......... -------------- ------------------•--------------------------- ---------------------- ------------- --------------------------- ----------------------------•-----------------------------r---------•------------ •---------------_-..---------------------------------------------------- ----------- FINAL INSPECTION BY:... . . ............... /�- Date ' - ; SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ava. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracyr California .. 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