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FOR OFFICE USE: _._ -----------__ j(?E skill APPLICATION FOR SAN? ITATION PERMIT Permit No. � `'__` _�� . ..................---.- - ---- --- ---- -------- (Complete•in Duplicate) '"'""',_c---.._'"'----:`.---__"`�-1 .1'This Permit Expires"I'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 descrlUed. This application is made in compliance with County Ordinance No. 549. .� ' JOB ADDRESS ANDCATIOQN---- (� - --------- ------------------- Owner's Name----- C-� ------------------- ------------- --- Phone-4-7•7=.-42X4-3 Address ---------------- -----------------------------------.-------- ----------------•-•--------------------- Contractor's Name d ��.= C' '-t-"�----------- --------------------- Phone-4t.. 6.' ��----- le. Installation will serve: Residence 9 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ t Number of living units: __1---- Number of bedrooms -- Number of baths_1____ Lot size __. _ ._ ____ ____________________ Water Supply: Public system ❑ Corrmunity`system-El"-Privafe'�Depth to Water Table-.0_ 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 K New Construction: Yes ❑ No 91. FHA/VA: Yes ❑ NOX 4 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_________________Distance from foundation____._._.___._.__.. Material ------------- ---------..________-_--....__.._. I ❑S1Lk.5T'+ No. of compartment----------------------- --Size----,--------------- -----------Liquid depth -----Capacity----------------------- Dispo Field:: Distance from nearest well..&.g- -_-__Distance from foundation__- ..._-.Distance to nearest lot line-240--____- Number of lines----��-Cf)A- Len th`76f each line _.___ z �7 - � 9Q is Width of trench « Ift Type of filter material.iK ��x _----Depth of filter material___4_S-----------Total length_._410----------------______._._ Disfance 4o,nea'est.well_.f47,0.._____Distance tom oundation-__ -----Di9tdnce to nearest lot line---,G _-... {dumber of its_- +� g SizE: Diameter-- r! P Linin material � ( Depth t Cesspool: "Distarce:from"nearest well ----------------Distance from foundation---_---------- -.Lining material_______________________________-.__. ❑ Size: Diameter- -- -------------- ----------------Depth------ ------- ---------- ----------- ---- Liquid Capacity---------------------- ----gals. Privy: Distance#from nearest well-------------- ----- ---- ----------------Di tante from nearest building r� ❑ Disfance to nearest lot.lire ------------------- / - - ---- -----j '------ : : ----------- ---- - ----------------------------- . Remodeling and/or repairing' [describe) - -------_---------•--------------•---- ----------------------== -------------- ------- -----------------_- ------------------------------------•---------------------%---- ----- - 1 ---------------------------------------------- I - -- - ---------------------------------------------------- --...... ..:Y t I hereby certify,that I h prepared this ap lication and that the work will be done in accordance-with San Joaquin Count jordinance5. State laws, an rut s and regulatio /of the San Joaquin L cal Health District. i (Signed) f -' --- --- ..(Owner and/or Contractor) } k - ` -- --------- BY= �. ..... i � Title s (Plot plan, showing size of of ocation of system in relation to wells, buildings, etc., can be pla d on reverse side). FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY 'r - - - DATE 6'd� ---- -- 1 - -------------------------- REVIEWED BY---------------------------- - ----------------- --------- - ------------- ------------------------------------------- DATE--------------- BUILDING PERMIT ISSUED-------- ------------------------- -------------------------- ---------------------- ---._: DATE------------------------------------ Alterations and/or recommendations:--------------------------------- - --- ----------- ----------------------- ------------------ ----------- -•-------•--- 0 -------------------------- ........ ---- ------ ------..----- . .--. -- ..... ------------------- - ---=-- --- ------ ------------- __/ ... } FINAL INSPECTION BY:....__. ----------------------- Date.- 1 .�. �_'_. ._..----- -- --------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Sfockton,California Lodi. California Manteca,California Tracy,California E.H.9 2M 1.67 Vanguard Press