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FOR OFFICE USE: h4:ilt) APPLICATION FOR-WMITATIOK PERMIT Permit No. .._..... ...._.. -------- ------------------------------- -- (Complete in Duplicate} i Date Issued -....?--.... .. ------------------------------" This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and,in all thonork herein des bed. This application is made-in-compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-h- _-- _ -- - ----±--- ------------------- --y--'------- --•.:.. A/4114, j�� 7 Phone.......y--------_-•---------•-- Owner's Name-------{= 4-�-....... �---------••-•-- : ----•-------•---- ---------------------* ��e -... ? --------=----------------------4......---------------------------------- ................. Contractor's Name.__ -----. •--- Phone----------------------------------- _ . Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 5t Number of living units: ._1----- Number of bedrooms -------- Number of baths __q--- Lot size .. .- ---------•••--- (� Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table -- __ ft. Ltd Gravel Sand Loam Clay Loam ❑ Clay ❑ P�® Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gra ❑ y ❑ Y Previous Application Made: {1f yes,date--------------------) No jW New Construction: Yes X No ❑ FHA/VA: Yes ❑ No ❑ 1iI i TYPE OF INSTALLATION AND SPECIFICATIONS: - (No septic tank or cesspool permitted if public sewer is available within-200 feet.) Septic Tank: Distance from nearest well--- Dista ce from foundation.__1q.........Material---- ................... No. of compartments-.--=-X---------- q p ----------•-------Capacity- ---- I Size_4------ - ._--Li uid de h----- J 4r Disposal Field: Distance from nearest well-_� -......Distance from foundation.___ .v . ....... to nearest lot line...s _.__G Number of lines----•.•.�-- ----- -- Length of each line-----�_�--------------Width of trench.... ................... "4 : __ Type of filter materia Depth of filter material___— -----------Total length---l. ............................. Seepage Pit: Distance to nearest we I_____________________Distance from foundation____.....___----__..Distance to nearest lot line____-.-..___..... ❑ Number of pits---_-----------------Lining material----------------------Size: Diameter-----------------------.Depth----- __ Distance from foundation material_..___......__-_--______------ .___-- Cesspool: Distance from nearest well___________ ❑ Size: Diameter-------------------------------------Depth.---•-----------...---------------------------------Liquid Capacity---------•--•--------------gals.' Priv Distance from nearest well _--_---_____if----------------------------------Distance from nearest building-----_------------------------ Cl "Distance to nearest lot line------- ---------------- ---------•- --...---------------•-•--•---------------•-------------------------------- j Q Remodeling and/or repairing' (describe):----------------- -3--------------------------------.---------------...................--.------------------------------------------..------------. I If # ------------------------- ----------------•--------• -------- •-- ------------------------------------------------------------ -•---------------------------------------------------------•....----••-•---•----- i ----------------------------------- ---------------•------------------••--------------•-------••------••-------------------------------------------------••-------------------------- I hereby cert' y that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances. Ste aws,-and �requlaficns-6f th San Joaquin Local Health District. --------------------------(Owner and/or Contractor] (Signed) _ By:•--------------- --------------------------------�-------- ------------------------------------------------------ (Title]--------------------------------------------. M �"'(Plot plan. showing size of4lot,`location of.`system in relation to walls, buildings, etc., can ba placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---- --- ------------------------•------------•-------------------•--- DATE----1 --y---------------------------- REVIEWED BY-------------------- ---•------ ----------------------------- DATE-------------..._..-------•------ -------------------- BUILDINGPERMIT ISSUED---------------------------------------• --------------•-----—--------------•----------------------- DATE------------------------------------------------------------ Alterations and/or recommendations:----------------------------I-------- _--------•-- -- .... ----••---------------- •---•---------- ._ .,`� ---------- •------------ --- ---- - _- , . li �. ................. : . : FINAL' "INSPECTION BY: ----------------- -------------------------- Date , SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California , Manteca,California Tracy,California A EB 9 HEv13Ea B•69 PM 661 AMAS �;S