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-- ---- -----rUK Urrlt,t u�t:------ - • •- / / - Ul } APPLICATION FO NITATION eERM1T Permit No. ...,1 -------------------------------------------------•------ (Complete in Duplicate) Date Issued .._ . --- ------ -- ----------------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Leal Health District for a permit to construct and install the work herein deserb d. This }p is n js�,nads in pl' ith Ordinance No. 549. JOB/ADDRESS/A/ND LOCA 4d [. �{ 44 x� 1 - "- lam• � s v� ..... ........ ti�p Owner's Name O d� - -- •-- -------------------------------------------------------------- Phone------------------------------------ Address........................•--•• - J r Contractor's Name - !,...__ /, Phone Installation Al. serve: Residence [-] Apa ent House ❑ Commercial ❑ Trailer Court ❑l ,,M1ot_el ❑ Otherx Number of living units: ________ Number of bedrooms ________ Number of baths ........ Lot size !l r;7____________________________________ 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❑ Hardpan Previous Application Made: (if yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic ank: Distance from nearest well----_-'�__�_____•Dista rf fro found�fion_____/__12_______._.Material... . ........ ..................... \` p j� - � - eta-�------ No. of compartments---------- -----------•--Size.-. �rx_—tX..d.___Liquid depth._...S..----------------Capacity__J.,,'-- ....... Disposal Field: Distance from nearest well_________________Distance from foundation-------------------Distance to nearest lot line................. ❑ Number of lines---------------•-------------------Length of each line------------------------------Width of trench-----------------------------..... Type of filter material---------------------_---Depth of filter material-----------------------Total length........................:__-__---__--.-_-- Seepage Pit: Distance to nearest well----_-----------------Distance from foundation....................Distance to nearest lot line......__.______-. ❑ Number of pits----------------------Lining material...........------------Size: Diameter-----------------------,Depth------------.-._.---.---.-.------ Cesspool: Distance from nearest well-----------------Distance from foundation---.---------------.Lining material------------------------------------- 0 Size: Diameter--------------------------------------Depth-------------------------------- -------------------Liquid Capacity............................gall . Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____..________-_-_--------___.__._____._. ❑ Distance to nearest lot line----------------------------------------------- ••------------•---------------... r Remodeling andAQr. r (describe):----- - ----- ------ �iI'_••- -------- tl ` ------- ------•-••---•-•-•. ------------------------------ ---------------------------------------•-•--..............-------------------------------------------------------......----------------------------------------------------• ------------------------------------••--- ------ -----•------------------------------•--------------------------------------------•----..........--------------------------------------•----------••--•--------------------------...-------.._......---------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I s, and rules and regulations the San oaquin Local Health District. (Signed) -� -------- -------------'�------------------------------------------------------------(Owner and/or Contractor) _ By:.—- --�� ...... -•---•-- ---.......... ---------------- -- --------------- -----+---------------------(Title)-----------i----------------------------------------------- (Plot plan, showing size of lot, loc tion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPL CATION ACCEPTED BY --- ~___----_------------------------------------------------------------ DATE__-----• •--- G ------------- REVED BY------••--•- --•------------------------------------------------------------------------------------------------------ DATE-------•-----••-------.... B6' ING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------------------...:..... A. ations and/or recommendations:-----------•------------------------------------•------------•----•-•---•--•------------------....----..__-----------••---•-----------•---................... •----•--------------------••------------------•------------•-----------•--------------------------------------•--•------.----•---------------------------------.-.----•----------------------------------....----------------- ---------------- -•--------•.---- FINAL INSPECTION BYDate-- / - - ------------------------- 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 fj xrr''��ES 9 REVISED B-59 YM 8.61 ATLAS