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APPLICATION FOR SAMTA�JON PERMIT Permit No. (Complete in 6uplicate) This Permit Expires 1 Year From Date Issued Date Issued .fi��__- __ _-. 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 wi�y Xnty Ordinance o. 549. JOB ADDRESS AND LOCAON 77 fes..... �1.�� --------- - ------------------------•------------------------------------- Owner's Name---------v----- b' -------------------------------- -------------- Phone-------- --------------------------- Address - �1-moi•- e- d --.e-------------------------------------------------------------------------------------------------------------------------- ---------------- Contractor`s Name ----------•-- ------------ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:~___ Number of bedrooms J__ Numbei_of baths ___/__ Lot size. --------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑.,,Gravel ❑ Sandy Loam ❑—Clay Loam ❑ Clay ❑ Adobe[n`_Hardpan ❑ Previous Application Made: Yes ❑ No [New Construction: Yes 2-.—No ❑ FHA/VA: Yes �o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available wi thin 200 feet.) ._ _____Distance from foundation____ ____:_"`� .Mate!___��__- ��'�"-``-- ----- 5ep}ic Tank: Distance from nearest well_____ // ��• ; ---- ®�� No. of compartments______�__i_____ ___Size_ _4�_ 's�{ --.--_Liquid deptfs ' ______- Capacity____.p��____ i � /� 4- 1 Disposal Field: Distance from nearest well---.--`�?.__.._Dista from'foundation____________________Distance to nearest lot line______._____ � .. , ' ri Number of lines_______ ___- r'- Length of each line----"—___.___ :_x__..Width of trench___. -______.____________. of filter material_4_/ ✓__ epth-of filter,_ma erial____1 ��__-l--Total length----- Type Seepage Pit: Distance to nearest well----,.-'_ _ ____ _Distance from foundation-----/X, ------- to nearest lot line------- [gam Number of pits._-___�r----------Lining material__/ Zlfk_.Size: Diameter._.,_ _ _______Dept --X-! s� Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material_._.______-------_______-___________ ❑ , -------------------------------Liquid Capacity--- ------------------------gals. k Privy: Distance fromnearest well-__________ ____D-epth Distance from nearest building Distanceto nearest lot line-----------------------------------------------:----------------•-------------------•----------------- ------------------------ - ----- Remodeling and/or repairing (describe)=--------- -------------------------------------------------------------------- ------------------------------------------------------------•---------------------------------------------------------------------------------------------------•----------•----------------------------- ------------------------------------ -------------------------------------------•----------------------------------------------------- ------------------------------------------------------------- ------------------------•----------------------------------------------------------- ------------------------------------------------------ - -- - `1 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. (Signed) /- �2 '" - - ._ (�r Contractor) BY:------------------------------------------------- -------------:------ -------------{Title) f ----- ------------- (Piot plan, showing size of lot, location of�s stem in relation to wells, buildings, etc., can be placed on reverse side). --�" 'FOR-DEPAR?IvIENT USE ONLY APPLICATION ACCEPTED BY------- ------ !D;-------- ------ ---------------------------------------- DATE---------- �[ �/� �� ; '- ----------------- 1 REVIEWED BY--------- --------- DATE ------------------ BUILDINGPERMIT ISSUED------------------ •----------u--------------------------------- ------------------------------ DATE------------------------------------------------------------- Aiferationsand/or recommendations---------------------------------------- - ------•---------------------------------------------------------------------•---------------------------------------- ------------------------ -----•- ------------------------------------------- ----------------------------------------•---------------------------------------------------•--- ---------------------------- ------------- -------•-------------------------------------------------------- -------------------------------------------------- ------------------------------- -------- --------------------------------- ----------- --------- -------------------`p ------ ----- C � FINAL INSPECTION BY:.._Ok-- ------------------._ Date SAN JOAQUIN LOCAL HEALTH`,DISTRICT 132ySjcamoie'Sfieot ` - 814 North "C" Street 130 South American Street 300 West Oak Street Y } Stockton. California Lodi, California Manteca, California Tracy, California E5-9-2M Revised V59 FT Co.