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PERMIT APPLICATION FOR NITATION Permit No. _.--��-=Z=---- (Complete in Duplicate) Date Issued Applica{ion is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. '°his application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_...___________ __ _____ __ ----- -- ------- -----. Phone._.- �' Owner's Name-----=-----------•---•• -------•--••---•-- �J Address------------ -�-`-'`•'-`-'-`-��'•--------••-----------------------------------•-•------•--------•-------•---.._....--•----•-------•----------•-----------------•--------• ---��---II•yy------------•---ff-��-------- 1 ''`-'---------- ---------•-----•-----------.. .................................. ------- ------- ------------... Phone-1�'�7-- f Contractors Name.__-_-_-- -tA_-�'------ o el El Other El ins+aIle+ion will serve: ' Residence Apartment House F-1Commercial ElTrailer Court ❑ b 6 � ..►6k_% ----- 1 � ------ Number of living units: _r___._ Number of bedrooms c'. Number of baths --_ --- Lot size .___.___ ._--.-_ _ ` Public sys#em Ml-"Community s Private ❑ Depth to Water Table��- ft. Water Supply: Y Ystem ❑ f❑ Adobe ./Hard an C]Character of soil to a depth of 3 feet: Sand El ❑Gravel ❑ Sandy Loam Clay Loam Clay ❑ B p Previous Application Made: Yes ❑ No New Construction: Yes �No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) _v I Septic Tank: Distance from nearest well-_'_....:.4- Distance from foundation--._---_____--- Material_----_______.__----------------------- - Ls uid depth---------- --:------------Capacity---- ------------------------- No. -- fE. Na. of compartments Size------------------------- q Dis osa = Distance from nearest well-.- ____.-Distance from foundation....................Distance to nearest lot line.._____..___..__. x p ------ -Len th of each line----------------- -.------.Width of trench----------------------------------- 'Depth Number of.lines------------------------ g -Total length ----- - g - - ----------------- Type of filter material--------------------- --Depth of Filter materia___.._-_.___..._.. -- . Dist once to neare.Tlolin -------- foundationSeepage if: Distance to nearest weIL. Y`�--.-----Distance froSize Diame ...... ---_- r NNK, umber of pits.-----)--------------Lining material_�;•:�--------- --------------- f cesspool; Distance from nearest well-----------------Distance from foundation.----- -- .--:i__Li�nurd Ca acit ---gals. Size: Diameter----- -------- ---=--- ---- --- --- .Depth 9 Capacity - Privy: Distance from nearest well------------------- Distance from nearest building------------- --------•-----•------------- -,-----.- Q -Distance to nearest lot line------ - ----------- ------_-------------- r -------- /o �, : _ � ---- _ Q and/�r�epairing (describe):--- Remodeling ,- _-- .----�--------••------_--•----- --- I 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, - -- ____--(Owner and/or Contractor) -.- - - Title - - - (Plot plan, showing size to+, location of system in relation +o.weNs, buildings, etc., can be placed on reveFse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------ - - DATE---------V"`•------------------------------------------- -- ---- ---- DATE------ •-- ---�--�•------=------------------••-------- ---- ----------------------------------------- -- REVIEWEDBY---------------------------------------------- --------- 'DATE---------------- ---- BUILDING PERMIT ISSUED-------- ------•------------------- --- ----------------- `� Altera#ions and/or recommendations:.:..............._._--- -- -. .. ----------I --��- - - - ----------------- - ---------------------------- ' --- ----------------------•--_- FINAL INSPECTION BY:----- —c� � ------------ Date. r SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street Trac California Stockton, California Lodi, California Manteee, California Y� IES-9 14544 ATWCo�