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1� ,NITATION PERMIT No.APPLICATION FOR _ (Complete in Duplicate) Date Issued -_3/!- • is lication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 'his application is made in compliance with County Ordinance No. 549. J JOB ADDRES AND'L AT -_.----------•- '' - i Phon t ---- ------------ Own Na -- _ l' '''f. -•---------- ----------------------------------------------------------- Address _ - ----- Phone. _ ,. -•-r--------- Contractor's Name_____________ `- -- Other ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Installation will serve- Residence Apartment House ❑ 1� / Number of living units: _. __.__ Number of bedrooms -- Number of baths _,1 -- Lot size --- 2_C� Water Supply: Public systema-Commuriity system❑ Private ❑""Depth to Water Tables-/----_Oft. //�� Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 11 Hardpan ❑ Character of soil to a depth of 3 feet: Sand C] FHA/VA: Yes C] No� Previous Application Made: Yes ❑ Ng ] New Construction: Ye No El I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if.public sewer 1.is available within 200 feet.) Material T nk: Distance from nearest well_________________Distance from foundation_-_______-_______-- ` No. of compartments -----Size--------------------------------Liquid depth--------------------------Capacity i osa Fi��d: Distance from nearest vvelL._.___--_.-----.Distance from fau1etlation-------------------- __.-_---- - .-W nth oftfrench est lot line----------------- 4r sp /" Number of fines-----------------------------------Length of each l ---------------------------- ------------- , Depth of filter material----------------- ,---Total length------------------------------------- Type of filter matenaL__.___- p ..Distance to nearest lot line t / �-Zi� _. Distance from ndatio _._ .- , Se page Pit: Distance to nearest wel; ----- Depth__--- Number of pits___-1_______________Lining maferial _ _--- ---.-----Size: Di eter__-- L� Distance from nearest wellDistance from foundation___________ ________L'nkSg material_____.-__-,____----.------------- Cesspool: _Liquid Capacity----------------------------gals. " ❑ Size: Diameter --------- -----------Depth---------------- I Distance from nearest well -------------------------------------- Distance from nearest building--------------------------------------- i Privy: ------ - ❑ - Distance to nearest o ine________ ____ ___,-----------• ---- ----- __ •_ _______________________________________________________________ Remodeling and/or repairing (describe -- "_- �rtr �;,�� `: ----- -------- ----- -- ------- �•------- ---------------------------------------- ___ _ _ p PP ------------ ----- District. I hereby certify #hat YI have prepared this application and that the work will be done in accordance with San Joaquin County y E. ordinance�4fe laws, and rules regulations of the San Joaquin Local Healt ned -_ --(Owner and/or Contractor) (Siq }- /: -----(Title} A------------------- By___________ __ ___--______________.__._________-__-__________________ of lot, location of system in relation to wells, buildings, etc., can be placed on rev sey e). (plot plan, showing si� FOR DEPARTMENT USE ONLY DATE--- ` -----`----- --- ------------------ ------ ---------------- APPLICATION ACCEPTED BY_ -----------•--- -------- DATE-------------------------------------------------------- -------------------------- _ ..---•--- --------------------- --------------------------- - REVIEWEDBY--------•------------- --------- ---------------------------------- -- --------• DATE-----------•------------------ -------------- BUILDING PERMIT ISSUED---_--•------------------------------------ - Alter. ions and/or recommendations:- --=------- --------------------------------------------------------- �_ - ---------- --------------------------------------------- V---�-------------------------- --------------•- __________________________________ y .------------------------------------------------------- --------------------------------------- _____ _________________________ _ - F1NAL INSPECTION B �•- ----�- -�---- ------ -----� ------- ----- ------- -- - Date_.,- ------ ---- ------- ----------------- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street Tracy, California Stockton, California Lodi, California Manteca, California ES-9-2M Revisea 1-57 FY-CO. t