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APPLICATION FOR PERMIT Permit No. .__ 3-0-. :, u (Complete in Duplicate) 4 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 madq in compliance with County Ordinance No. 549, JOB ADDRESS , LOCA TION ----- ----------- --- ------ ------------------------------------------- /0 Owner's Name--- - %T ••� ---------------------------------------------------- Phone------------------------------------ Owner's --+--- ------•-----••------ --------------------------------------------- --- Contractor s Name_______________ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court 0 Motel Other ❑ ' Number of living units: __-_L Number of bedrooms __ --- Number of baths .__ -. Lot size -------------- Wafer Supply: Public system ❑ Community system [IPrivate 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: Yes ❑ No E( New Construction: Yes PRr"No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet:) Septic Tank: Distance from nearest wel�� pistarice from oundation__._Ii -___-._ Materi I------- ._____________ No. of compartments . -_--_ Size Z¢1 __ Liquid de h----------- Ca acit �Q_ . p j . --- - q nn P ------ capacity - Dispos I Field: Distance from nearest weA��__ t Distance from foundation---- i _,_.__.Distance to nearest lot _ f ( ' Number of lines___________ _____ _____ Length of each line________ .t _.______.W1dth of trench.__.__..___ _ Type of filter material-- Depth of filter material---------- ---..Total length------------- .----------------------- Seepage ---+_.__- .--f- Seepage Pit: Distance to nearest well ._-__-_--------------Distance from foundation___________________.Distance to nearest lot line_-._-.---__-_-___ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- v Cesspool: Distance from nearest well---------- -----Distance from foundation-----.------------- Lining material.-____-------_-__.__--_...___________ Size: Diameter--------------------------------------Depth ----- d Capacity_ gals, l � Priv Distance from nearest well-------------------------------------------------Distance from nearest building _--. N ❑ Distance to nearest lot line---------------------------------- -- ------- --------------------------------------------------------------------------•-------------- : {� Remodeling and/or repairing (describe):--------___--.._. 1 e ........---••-•-----•------•-• ------------------------------------------------------------------------------------------------------------------------------------------------ ---------------•- -------------------------- -------------------------------- ----------•-••----------------------------------------------------•--•----•--•-----------------------------------•--------------------------•-•------ -----•------------ ----------------- v --------- --•-------------------------------------------------------------------------•---......- -------------- ---------------------------- ---------------------- --------------------------------- 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. 1 --"'' Owner and/or Contractor (Signed} '�' ' --------------------------------------------------------------------------- -----(Title)----------------------------------------------------------- -- (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 1 APPLICATION ACCEPTED BY DATE.-:t§ REVIEWEDBY ---------------------------------------------- DATE--- - ------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------- ;JP"-'-`- --- ----------------------------------- Alterations and/or recommendations-------- ------------------ ------------------------------•---------------------------------•-••-----------------------• -----------•------------------•-------- -----------------------------•---------------------------------------------------------------------------------------------------•--....------------------------------------------------------------------ -•---••-•-------- ----------------------------------------------------------------- -----------------------------------------•---------- ..._-..------------------------------------------------------------------------------------------- -------------------------------------- ------ ------------------------•------- ---------------------------------•------------------------•----------------------------------------------------------------------------------- FINAL INSPECTION ---------------------------------------------- Date....��------- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M 10-52 Revised W-2100