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FOR OFFICE USE: -------------------------------------------------------- APPLICATION FORvSANI f ------- -- - -------------------------- ---------------- ATION PERMIT Permit No. _ _z__ 7 ------- ---------------- --------------------------- (Complete in Duplicate) - 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. JOB ADDRESS AND LOCATION------------094 ----- low- ------ = � ------------------------------------------------------------------- Owner's Name----------------------------- �� ••------- ------------ Phone.��-I ��7 Address-----•--------------------------------•--•---------- -----------------------------•--------------------------------------------------------------------- Contractor's Name--------------------------------------- -� Phone ""`" Installation will serve: Residence R'"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ -_ Number of bedrooms ___9_ Number of baths --�_-- Lot size ----_-__. 7-A.- -___.__.�,_Y_b&6______.___ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -7---- 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 [3---FHA/VA: Yes ❑ No-Ef` E TYPE OF INSTALLATION AND SPECIFICATIONS: ?div- CA6 pt.g5,a+, F i�S`4� et ,- (No septic tank or cesspool permitted if public sewer is available within 200 fe . F - �"Septic'Tank: qq PS L;'+l No. of compartments--------------------- ---Size-------------------------------Liquid depth--------------------------Capacity-------•----�--r-- - s (sposal Field: Distance from nearest wet ....Distance from foundation-_ c --_--.Distance to nearest lot line-----S.- ❑/ Number of lines-------------- _..___--------Length of each line----------- ----------Width of trench.......- g G---De Depth of filter material-----1 ---------Total length-------Ak-P---------- ------- ------ _v Type of filter material--- __ p - - Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------.------Distance to nearest lot line__-_-_._--.._-_-- IDepthA t ❑ Number of pits----------------------i-fining material--------------------- Size: Diameter.-------- -- ------------------- - ----- Cesspool: - -- t`+ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- materia!--------------_---------------------- Size: --------.----_-- -Size: Diameter----- - --------------------------- Depth_ -------------------------------- ------- --- Liquid Capacity-"--------------------------gals. Privy: Distance from nearest well ---._------ - ------------------------ ---------Distance from nearest building____ --------------------------- ------. ❑ Distance to nearest lot line---------------------------------- ------- ----------------------- ---------------------------------------------------------------------- Remodelin and/or repairing describe ___ _ _______________ ________________ ______ ----------- t,.`�. - - ---- -------------------------------------------------------- ----------- --- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. 4 (Signedy�`4_1_ � --_ (Owner and/or Contractor) By------------------------- ---------------•-- --------------------- ---------------- ------------------------------- - -----(Title)----------------------------- --------- - -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). T Y i FOR DEP TMENT USE ONLY APPLICATION ACCEPTED BY...... r 5r` --- - ------- ------ ------ ---------- ----------------- -- - ------------- DATE----------------------------- .�-<_-------------------- REVIEWEDBY------------- -----------_-- -- --- -- - ------------------------------------- ------------------------------------------ DATE--------------------•-------------------------------------- BUILDINGPERMIT ISSUED---- -------- ------------------------------------------------------------------------------- -- DATE--------------- ------------------------------------ Alterationsand/or recommendations----------------------- - ------------------------------'-------- --------------------------•---------------------•------•--•----------------•--- --------- --------------------------------- ------------------------------- --------------------- - ------------ -------------- ------------ ------------------- --------- -------------------------------------------------------- -"------ --- --------------------- - - - ----------------------------------------- ------- --------------------------------------------- ------ --------------------- --------------------------- -------------------- --------------------------I•-- - ---- --------- ------------- i FINAL INSPECTION :--- ----------- Da- te-----------_ ._ .lf..-4 ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Te Manteca,California Tracy,California F.P.0 0.