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L7 FO OFFICE USE: � 'ATION PERMIT {. Permit No. . _ �! " / _ APPLICATION FORAtvi y . ------------ (Complete in Duplicate) bate Issued _ -Jf�`�, --�--------------- ---- ------------------- I P ,� "._""- --_ This Permit Expires 1 Year from Date Issue ------------------ - - 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 compliancewith County Ori ante No -1 ------------ JOB ADDRESS AND LO -- Phone_-'.7 ----•--- ---•---•---------- Owner's Name-- .CEJ---- ----••---------- Address . --- --- one- .� �y � r _ �--- -- --- -- ---------�--- -------- - Contractor's Name------ P Commercial Trailer Court ❑ Motel ❑ Other ❑ " Installation will serve: Residence �A artment House ❑ ❑ Number of living units: ---/_ Number of bedrooms _. - Number of baths ________ Lot size ---------------------------- _--" __ = Water Supply: Public system �ommunity system El Private F1Depth to Water Tablea f� Adobe e_-Hardpan Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [I Clay El Clay No ❑ , q ❑ 0" Previous Application Made: (if yes,dote..�--t-- -�7-- No ❑ New Construction. Yes No FHA/VA: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: within 200 feet. [No septic tank or cesspool permitted if public sewer is available w J 0 tic nk: Distance from nearest well_________________Distance from foundation Liquid de th-"Material---------------------------------------Capacity----------------------- S -------------------------- 1-11-7 -------- ----• q p No. of comportmems------�-•------------ -�-- ize_____-"-------- 'po igid: Distance from nearesfi well x .-__ Distance ofeach line anon_"--------------=-Distance oftfrench est lot line----------------- sem/ Number of fines--------------------- Type of filter material_________-------------Depth of filter material____._________.---�--.�'otal length------------------------------------------ Type ._.______------,_---------- --------� I Distant m foundation__. -- Disnee t° nearest lot line--l_ __._" h Seepage Pit: Distance to nearest weld _ �7U Linin material-YT -'C1t--Size: Diameter----J� - --------Depth_._ - --------- ®/ Number of pits-____ ______-_----- g Cesspool: Distance from nearest well-------_---------Distance from foundation----------------- Lining material Capacity---.----------------------- gals. ❑ Size: Diameter---- ----------------------- ---------Depth------- --------- --------------------------------° Distance from nearest building.----.-"---------------- Privy: Distance from nearest well---------------------------- ----------------"-.--.. ----------------------- ❑ Distance to nearest lot ins__________________ � --------- ------- ---Qom'<��`- -------�-��--- -��---- --- Remodeling and/or repairing (describe):-------- --- --------------------------_-------. ------------•----------- t-d ------ - -------per ---------------------- ------------------------ ------------------------ . ! h"ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S#�te law , and rules nd re lations of the San Jo lain Local Health District. r f� Ownpr and/or Contrattort (Signed) /f �- - ------------ -- -- --- ------------ ------ -- �, �- -------[Tits -qon el-- [Plot plan, showing size of lot, location of system in relation tow , buildings, etc., can e p cverse FORDEPARTMENT USE ONLY i`tl DATE------------? �� ----------------------------- APPLICATION ACCEPTED BY - DATE--..---.._ REVIEWEDBY-_--' ------------------- --- --- -------------------- --------------- - BUILDINGPERMIT-ISSUED----------------------- --------------------------------------------------------------------------- DATE - -- Alteratioraa and or reco men do s:- _... --- ----------- y ,. r-- -'-- --------------------------------------------------- - ., - ---------- ---------------------------------- -------- -- -•--------------- ------ -.-------------------------- ------------ -------- ------- -------- - -------- ..... - - _7 - — -------------- --- ---- ------------------- FINAL INSPECTION BY------------ ---- ---_.------------------------------ -- Date k SAN JOAQUIN LOCAL HEALTH DISTRICT 11501 E Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 west 9th Street Stockton,California Lodi,California Manteca,California Tracv,California