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FOR OFFICE USE: a --------------------------- -------- -------------------- _ -------------------------------- ------------------------ APPLICATION F01n,/►NITATION PERMIT Permit No. -- - -------- --------------------- --- --- ---- ------------ (Complete in Duplicate) Date Issued , :- T --------------------------------------------------..--.--. I This Permit Expires 1 Year From Date Issued��''_ Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-----•- ,_49— ---: _ ,--- Owner's Name....... �?�.- ------------------------- -- -------------------------------------- Phone------------------------------------ Address-----•- !-,12' -•-•-• - ---------- Contractor's --------Contractor's `Name- __�-------------------------------------------------------------------------------------------------------------- Phone---------------------------------- Installation will serve: Residence C Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --1-_-- Number of bedrooms -.3 Number of. baths -f----- Lot size ---- A -- ��_-G--------------------------. Water Supply: Public system E] Community system [IPrivate'❑ � Depth to Water Table-IOFt. Character of soil to a depth of 3 feet: Sand ❑ Gravel p Sandy Loam) Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: .,T� V .(No-septic,tank-or..cesspool-permi++edrif=public-sewer-is-availe6le-within-200-fee+ - - Septic Tank: Distance from nearest well-----------------Distance from foundation------------------- Material---------------___----------_--.---------__-_-. ❑ No. of compartments--------------------------Size-------------------------------.Liquid depth.-------- ------ --------_Capacity--••------------------- ; Disposal Field: Distance from nearest well .s�-_CJ'--_Distance from foundation--f�:-v-----------Distance to nearest lot line---sr.,----- Number of lines-_____--f----------------------Length of each line-----/U`v-- ------------Width of trench-_�-`�--°-----_----_---- ----- Type of filter material---- ------------------Depth of filter material----.------------------Total length------------------------------------------ Seepage Pit: Distance to nearest we' Distance from foundation----------__- ---.Distance to nearest lot line----------------- ❑ Number of pits------------ t--�_oawNriing material------------------- -Size: Diameter----.------------ Depth-------------------------------- � Cesspool: Distance from nearest well-----------------Distance from foundation --_---_---------Lining material -_____------------.--____----------. ❑ Size: Diameter= 1°'"-----------------------------Depth------------- --------------------------------------Liquid Capacity-------------------- - - - --------+-- - - q p Y ----gals. � Privy: Distance from neva �st we ---------------------- Distance from nearest building f ------------- - ❑ Distance to neares ; lot line---- -- ----- --------------- -------- Remodeling and/or repairing (describ ] -- -------s----------------------------------------------- ----- ------------------------------------------------- ------------------------------------ ---------------------Q------- ------------------------------------------------------------------------•-----•------------------------------•--------------------------- r< I hereby certify thaf'Fhave p er pared this application and that-the work will,be done in-accordance with San Joaquin County � I ,f ordinances, State laws, and rules and regullalfions of the San Joaquin Local Health District. (Signe 71 - - -..C -------------------------------------•----------_---- --------------------(Owner and/or Contractor) (Plot plan, showing size of lot, location of system in relation to wells, buildings,'etc.,-can be place d'on"reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ---------------------------------------------- DATE---' --- - REVIEWEDBY------------------------------- ------------ --------------------------------------------- --------------------------------- DATE------------------------------------------- ---------------- BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------- ------------- DATE------- Alterations and/or recommendations:-----------------------------" ---• - -------------------------------------------------------•------------------------------------------•------------ ----------------------- - ------------- -----------•------------------ ----- -------------- -----------------------------------------------------------------•-------------------------------------------------- \\� ------------------------------------------ "1? ----- --------------- ------------- "-- -------- ----- ----------------------------------------------------------------------------------------- -------------------------------------- •----------- FINAL INSPECTION BY:. --------------------- Date. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Lodi,Colif•orn�ia - Tracy,California Stockton,California Mantecw California F.P.CO.