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FOR OFFICE USE: -------------- -__� h--_�'........ APPLICATION FOR-,Sir TATION PERMIT Permit No. --------------------------------------------- (Complete in Duplicate) Date Issued ---------______----------------------------------------- This Permit Expires I Year From 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 ATIO -wl ____:�------------------------------------------------------------- Owner's Name -------- ------ Phone----------------------•--------•--- ----- --------- -----------•--------------------------- Address_--_- _- __ ------------ Contractor`s Name -------------------------------••--'--------------------- Phone--------.------- -----••---------- � gf Installation will serve: Residencepartment House ❑ Commercial ❑ Trailer Coubt ❑ Motel ❑ Other ❑ q e ' Number of living units: --/ sNumber of bedroom _ Number of baths __ Lot size, Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table,495t/ Character of soil to a depth of 3 feet: Sand ❑ Gravel f-] SandylLoam ❑ Clay Loam ❑ Clay El Adobe ardpan ❑ Previous Application Made: (If yes,date--------------------) No P`—New Construction: Yes ❑ No'FHA/VA: Yes ❑ No ' TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ._ Dista nce'from`foundation-------------------Material_-_►_-_________--___-_-________:____._-______- p compartments _ "Size--!1. -�------------Liquid depth- A.-Capacity_... ' - ---------- e tic n istance from nearest we ----------------- Dis osal Fie Distance fromnea est well--��- _ _ k i f p Number of line Distance to nearest Int Gneta____.- � DEstance frog foundation__ f� a ®�• T e of filter materral� w Length of each line__-9��____ Width of trent}1_ __ _________________________ - Type Depth of"filter material__��-___-___-Total length_-PQ______________________________ . - ', / . Seepage Pit: Distance to nearest well___��---Distance from fou dation_��Distan� to nearest lot li e_f,�__._ dumber of pits-__ - �-.-c Lining material_!' - Size: Diameter__ - I.- -- ��- Cesspool: Distance from .nearest well-----------------Distance from foundation--- material---_------------------_______________ ❑ Size: Diameter------- -----•--------------- ----- Depth---- Liquid Capacity gals. it Privy: Distance from neariest well__--_,__-___-____________-__-_._...W._Distance from nearest building______________________________________. ❑ Distance to neares ' lot line---------------------------•--- ---------------------------------------------------------------------------------------- ---------------- Remodeling and/or repairing (describe:---------------- ---------------------------------------------------- ----------------------------------------- - , i ----- ------------------------------------ x ------------•------------------------------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and-that"tKa work will be`done in accordance with San Joaquin County ordinances, State laws, and r les and regulations of +h San Joaquin Local Health District. (Signed)-------------- -- ------ �J �� - ( r Contractor) �w BY:------------------------------------------------------------------- �L -------(Title}_ P�� -------- -- (Plot plan, showing size of lot, location of system elation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY !APPLICATION ACCEPTED BY---------- �l` ----------------- ------//—/y'B1J---------- ---------------- ------�---------------------------------------- DATE-- 6 : VIEWED BY------------------- --------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ f-, ILDING PERMIT ISSUED-------------- ------------- - _ -- - ----- DATE-- �a---� .------------------------------ ~Alterations and/or recommendations: --. - �----------� --•--------- 1 ------------------------------- ---------------------------------------------------------------------- ---------------------------------------------------------------------------------•----------------------------------------------------•---------- FINAL INSPECTION BY .....Z` -- Date___--.j_�. / �-� _._ �._-.-_.-.._ - -- ------ - ---- -I---- -------- ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hoxeltoa Ave. 300 West Oak Street 124 Sycamore street 205 West 9th Street Stockton,California I-ocii, California Manteca,California ; Tracy,California F.P.0 O.