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` APPLICATION FOR „^ NITATION PERMIT Permit No. .......:. . ... .... j (Complete in Duplicate) Date Issued ---_IL _ ________�-__ l Applica{ion 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 with County Ordinan e No. d'7V . JOB ADDRESS AND LOCATION-------- ...... + Owner's Name.------ - Phone. - gf Address----•-------- --�d�f �'- ------------------------- - ------ Contractor's Na e ------------•-------••- -----------------------------------------••-----•--------- --------------- Phone --,r--.�� r Installation will serve: Residence J� Apartment House E] Commercial ❑ Trailer Court C] Motel E] Other El Number of living units: ___/_ Number of bedrooms ../-- Number of baths _/-___ Lot size ------ �+ _. a?r_��______________-__ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table��l{t- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobes Hardpan E] Previous Application Made: Yes ❑ Nor .New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance'-from nearest welLry Distance from foundgation,/ __f_____-Materiai____t -------- No. of compartments----:�_----------- ---Siz � �:___Liquid depth-1- ----__Capacity______.____�� posal Field: Distance from nearest weli_.—,- _Distance from foundation�49___...----.Distance to nearest line_______?.. Number of lines---------J---------------- - -----Length of each line-.--�r�---------------Width of trench_.__-- -.---•-••---------------_-- is L.-. Type of filter materlal _..._Depth of filter material___.f. .`°.___._Total leng}h_--_-_- 0-� Seepage Pit: Distance to nearest well _____----------------Distance from foundation--------------------Distance to nearest lot line----------------- ElNumber of pits----------------------Lining material-------'-----------:--.Size: Diameter----------------------.Depth--..--.:------.------------------ \ Cesspool: Distance from nearest well-----------------Distance from foundation---_----------------Lining material_----------------------.-_-_________ ❑ Size: Diameter------------------ ------ ----- ------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------------------.---------------------Distance from nearest building-.------------_-_--___________.._____.___. ❑ Distance to nearest lot line--------- -------------------•---------------------------------------------------------------- Remodeling and/or repairing (describer ----------------------------------------•--------------------------------------------------------------------------------- -----------------•---------•-----------------------------------------------__.-.-------•-------------------------------------------------•----•-•-------•-------------------------------------••---•----------------------._.. ----------------------------------------------•------- --------------------------------------------------------------•----------------------------------- ------ -•-------- ------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, StateVs, aa ndregulations of the San Joaquin Local Health District. Si ned -----'___________________ ---__.____.___._______.____.- :. .__ _(Owner and or Contractor f�/_ ---Title ---- ----- -- ------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be pla d on. verse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY --------- ------ -------------------------- ---------------------------- ------ DATE�---------•-•----------------•---•------------------- REVII=WED BY -�p- - . - -- --__-------------------------------------------------------------- DATE- ----------------------------------------------------- BUILDING PERMIT ISSUED---------- _ DATE------c5t--------------------------------------------------- Alterationsand/or recommendations----- --------- ---------------- ------ ---------------------------------------- ---------------•-•---------------•-------- ------------------------•----------- -------------------------------•---•-•-----------------------------•-- ----- - -----------------------------------••-•--------------------------------•-------------------------------•---------_-----••----------••--•-----•- ------------ - -------------------------------------------------------------------------- -----• --------------------•------------•------------------------------------------------------••----••----•------•---------..- -----------=------------------- - --- ---------------------------------------------------------------------------------------- ----------------- -------------------------------------------------------------------------- FINAL INSPECTION BY:. l!.-�7 ---------- Date------------------------------- ------------------------------------------ 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street- 814 North "C" Street Stockton, California Lodi, California- Manteca, California Tracy, California E5-9-2M 14SA40 ATWOOO 12-54 f