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t FOR OFFICE USE: I� II APPLICATION'i�- FQR !ANIS ATION PERMIT Permit No. ..6_ ------------- - -----------------------------------1 - (Complete-in Duplicate) � _. This Permit Expires 1 Year From Date Issued Date Issued__••_ •.. Application is hereby madehto the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made inlcompliance with County Ordinance No. 49, JOB ADDRESS AND LOCATION ---- ------------ Owner's Name 7 C�� .--�---------------------------- Phone_'j� 7. i - Address f{ _`��----- , - ------------------------ --- --------- Contractor's Name --- ------------- Phone---yGG...3 q�� ---- - ----- --------------- ----- - - Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer, o rt ❑ Motel ❑ Other ❑ Number of living units: __ Number of bedrooms -------- Number of bath/ size _..__ __ ____.__..____._ _._..__________________________ Water Supply: Public system Community-system ❑ Private E] Depth to Water Table � _ ft 111 Character of soil to a deptlh of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ • Clay ❑ Adobe Hardpan ❑ Previous Application Made.``. (If yes,date..... ........... ) NoISC New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ O TYPE OF INSTALLATION"AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) is Septic ank: Distancl1 from nearest well 20VPDistance from foundation__/_4:P-------Mat)rial - ---------------I........... - ---- --------24 No. of:icompartments_._.�_.-.-------_Size_r ._} Liquid depth_ - Capacity. ----- Disposa Field: Distanclp from nearest we�_Distance from foundation�'�.-_ _.Distance to nearest lot lines...... .... . Number of lines_...... �... 5...... Length of each line-- ___ rf----Width of trench------ Type -.-_.SQ.___. T e of filter material-.5,tot Depth of filter material__ ____.Total length YP 11 D P --� 9 Seepage Pit: Distance to nearest well--------------------- from foundation--------------------Distance to nearest lot line.--- .--------- ❑ Number of pits--- ------------------Lining material---------------.------- Size: Diameter-----------------.._..-.Depth--.-.__ ---------------------- Cesspool: Distance from nearest well ----------------Distance from foundation _- _Lining material....----_-_-------.----.-_-_._..._... Size: Diameter- -- --------- ----- ---- Depth--------- ---------------------------- -------------Liquid Capacity gals, Privy: Distar cle from nearl- _ _ est wel ______________________ ...____--__....---__._ Distance from nearest building.----------------------------------- ❑ Distance to nearest lot line - - --- --- -------------- --- - ------------- -------------------•------ ------•------------------------------------------------------- Remodeling and/or repairilflg (describe--- - ---- - -------------- ------_---------------------------------------------------- ---------------- - -------------------------------------------- ---------•--•---••-----•-----••---- .I------•---•--•-----------•-------• --------------•----------•---•---•------------------------------------------------------------------------••----- -------------------------- IM: �r I hereby certify that I�have prepared this application and that the work will be done in accordance with San Joaquin County ordinances. tate laws, an !rule an egulations of the n Joaquin Local Health District. k (Signed) ------------------------- er and/or Contractor) I 13 -- •------�I Titl Y -------- ( �-------------- - - ----- (Plot plan, showing size of lot,.lo ation of system in relation o ells, buildings, etc., can bee an reverse side). FOR DEPARTMENT USE ONLY �Ih o APPLICATION ACCEPTED BY-_ .. -------------------------------------------------------_1---- DATE----------•-- -s"... � -----•----------------- --- REVIEWED BY �� -------- DATE ---•----- ----------------- BUILDING PERMIT ISSUED-------- -- ------------------------------------- _ DATE Alterations and/or recommie�ndations------------------........-..---------------- - --------- -------------------------- --------------------------------•-------• ---•----- ------- -- ------------------------•---- -------------------------------------------- --------------------•----------------------- ----- -----••-•-•-------------- 1If ----------.................. ------------- 0-------- ---------------- ........... ------------- --------------- ------------------------------------------------ i ----- •--- 'iC 1 FINAL INSPECTION BY:'-- 1J-"------- ------- Date--- �` "-.` ...... - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave.• 300 West Oak Street 124 Sycamore Street 205 West 9th Street k Stockton,California Lodi. California Manteca,California Tracy,California 1 F.Fl.9 2M 1-67 Vanguard t