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FOR OFFICE-USE:-" APPLICAT16N FOR`�A�NII iAfION PERMIT Permit No. 12,A�e ....................____._-----_ --------- (Complete-in Duplica+e) Date Issued -• _-`"�' _______ ......._--------.----..-_.._. This Permit Expires 1 Year From Date Issued i. 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. r JOB ADDRESS AND CATION-----. r --- - ------------------------------ Owner's Name. --_ .-r- ------ ---- ----------- ---------------- ------ ----.. Phone----••-----•------------------------ Address }: `-r - / --------------------------------- '0- ------- ------------------------ � V - ---------- -----------------------• -----.---------•-•- �Phone...Contractor's Name---- _? - ----- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ / •rte Number of living units: .`_- Number of bedrooms --%T. Number of baths --j- Lot size ...1I�X.-..1_.7 ----------------- Water Supply: Public system ❑ Community system ❑ Private, " Depth to Water Table ------ - ft t Character of soil to a depth of 3 feet• Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe W Hardpan ❑ s Previous Application Made: (If yes,date___________________ ) No O New Construction: Yes ' No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No sepfic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest -.-_Distance from foundation-_./1Z__-.__...Material ----- No. of compartments.__---__Z_.______- Liquid Disposal Field: Distance from nearest weil_j"0__._-_._Distance from foundation-./Q__....---.Distance to nearest lot line----�3 Number of lines ---------------- Length of each line__... ;;;._...........Width of trench---J-7 -- -------------- ® i Type of filter materiaL_,4r& ¢ ------- of filter material-.-., 9... .._.Total length...... /sS` .................... `�� f Seepage Pit: Distance to nearest well-�r.!_(--------Distance f om f undation.._�Cd____.___- Distance to nearest lot line... Number of pits__ tl-.-.----.-.Lining material__ __.. Size: Diameter..T .� -----.Depth... ------- ______ (� Cesspool: Distance from nearest well ----------------Distance from foundation----------------- . Lining material-------------------------------------. ❑ Size: Diameter. Depth---------- ----- ---- - - - --- - - - -Liquid Ca acit -- gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------------- ❑ Distance to nearest lot line -------------- ------ -------------------------------....-------------------------------------------------------------------------- Remodeling and/or repairing (describe: - -- ---------- ---- ------------------------------------••-------------------•--------------•------•----- -------: ---------------------------------------------------------- ---------------......... '�-�c.r -------------------------------------------------------------------------------- - ---------- ----------------- ----- ----- ------- - - -------- - ---------- -------- ---------------------------------------------------------------•--------------------- ............ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sfafe laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------------------------ - ------ ------(Owner and/or Contractor) By: (Title)------- ---- ------- - ---------- (Plot plan, showing size of lot, location of syst in relafionaY6 wells, buildings,�ll�c., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - -- ------ DATE------------ --- REVIEWED BY ---- ---•---- -------------------------- DATE BUILDINGPERMIT ISSUED-------- -------------- -------- -------------------------------------- DATE---------------------------------- -------------------------- Alterations and/or recommendations:---------------- - ------------------- ;. f &7 -------------------------------------------------------------- ----------- ---------------------------•--- -------------------- --- FINAL INSPECTION BY:..-------- - - �G . --- . ------•----- Date--- 'f J UIN LOCAL HEALTH DISTRICT . } 1601 E.Noxetten Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California 4s�Manteca,California Tracy,California E.K.9 2M 1-67 Vanguard Press r- P -