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_ � ------------------- ------------------ -------- APPLICATION .FOR S�Nrv�,TION PERMIT Permit ----------------- ------------------ --------- ---- -- (Complete in Duplicate) ------------- - - - ------------ ------------------ ----- --- This Permit Expires 1 Year From Date Issued Date Issue Application is hereby made-to the San Joaquin Local Health District for a permit to construct and irYstalwo�rk herein described. This application is made incompliance with County Ordinance No. 549, JOB ADDRESS AND LOCATION__ _ zO-X____ �_ •_- ---_ C Owner's Name Cit �._-.. G !- 6 371 Address-------- ._—�..-.------------ ^.. . --------------------------------------------------------- -- ------ --------- _s ---------------- Contractor's Name � p.------- /`� --- ----- ----------------- Phone-------•----•---------- •-- Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I------ Number of bedrooms -2- Number of baths ;�2 Lot size __-_ _ _.x-_ c7-10_--_____ Water Supply: Public system ❑ Community system ❑ Privatez Depth to Water Table ft. ' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[J Hardpan ❑ Previous Application Made: [if yes,dpte--------------------) NoV 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.). Septi Tank: Distance from nearest well- ___Distance from foundation___--- ____--.Ma�rial-__( -CJS'-CG No. of compartments- -----------------Size--------------------------------Liquid depth_---`�--1?Z_ -------_Capacity---- Disposal Field: Distance from nearest well_.._ _ -___. Distance from foundation._ ____- -- �� .____.Distance to nearest lotne___ ..____ Type of,of lines---- __-- Length of each line-----7.. --- 1j-_---Width of trench-----4-__. �3:��iarf Number I filter material___ c�� ----Depth of filter material-_____IS:✓-_-.Total length---------Z 5-1'_______________._ 9 &_4-.Size: Dim ter._.._ _.�� -Cf Depth__----- % Seepa a Pit: Distance to nearest well---�.Q�-.______._Distance fro foundation_____ Distan e to earest lot line___- ____ Number of pits___-.�'.---_-.__ __ Linin material_.-__.. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___--____..___.__ ❑ Size: Diameter----------------- ------------------- Depth------------------------------ --------------------Liquid Capacity. .------------------------gals. I Privy: ; Distance from nearest well_----------------------------------------------Distance from nearest building--------I-----------------------______-.-. �r ❑ Distance to nearest lot line---------- ---- ---------------------------------------------------- Remodeling and/or repairing (describe)_--------_------------------------------------------------------ 1� :1 ---------------- - t I hereby certify th t I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la and rules and regulations of the San Joaquin Local Health District. (Signe )--------- ----- ------------------------ ------- - ------ ---- ------------ ----- -------------- ------------ ------------ ---- -------=---------� caner and/or Contractor) ---------------- P of plan, showing size of lot, location of s relation to wells, buildings, etc., can be placed on reverse-side). R DEPA MENT USE ONLY APPLICATION ACCEPTED'BY ---------------- DATE---- REVIEWEDBY_'------------------------................................. ------ ------ - . DATE-UILDING PERMIT ISSUED-------------------------- --- ---- ------ ----- ------------------------------------------------- DATE---- ----------- ---•--- ----------•- m ------ Alterations and/or recon ..__ ._ _ - -------- ----- •-------------- t ----- --- -- --------------------- --- -- -- ------ -- � 4°k- - - ns ----- ------------------------------ ---------------- ------------------------- ------------------------------------------------------ ----------- --------------------------------- a FINAL INSPECTION BY:.. ,�¢y� --------------------- Date-------- SAN JOAQUIN LOCAL HEALTH DISTRICT Y401 E.Ha:elton Ave. 300 West Oak Street 124 Sycamore Streetr 205 West 9th Street (1 - Stockton,California Lodi,California Manteca,California Tracy,California , F.P.CC. I