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APPLICATION, FOR NITATION PERMIT � Perm if'No.."�"1.�_--�-- (Complete in Date Issued Duplicate] ��~ S i ---------�""_-�- 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 compliance with County Ordinance No. 544. ----------------------------------- JOB ADDRESS AND LOCATION------ fhone------------------------------------ Owner's Name"-C-t"�!:! !_.-- '- `------------------------------- Address :__ ---- �''�r� - _ -• -- ' Phone Contractor's Name 2k = Installation will sere: Residence Apartment House❑ Commercial ❑' Trailer Court El Motel El Other E]v Number-of I.Mrig units: __1 Number of bedrooms _vZ--- Number of baths __ __ Lot size ------ZZ2--- °/ t'�---------------------------- , Water Supply:' Public1'system ❑ Commun'ity system ❑ Private X 'Depth to"Water Table -------- ft. Character of soil to a depth of 3 feet Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ .,Adobe2g Hardpan ❑ Previous Application Made: Yes ElNo [K New-Construction: Yes No ❑ FHA/VA: Yes El - FNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: _." (No septic tank or'cesspool permitted if public sewer is available within 200 fee+.} Septi Tank: Distance from nearest well-__.-______-----Distance from foundation-------------------.Material-.._""_"___--------.-_---_-_______-.-.- -_-__. i ✓�° No. of compartments -------------Size--------------------------------Liquid depth------------------------ Capacity-------------------- r Dispo al Field: Distance from nearest well-----------------.Distance from foundation___._________......Distance to nearest lot line----------------- Number of nines---------------------------------Length of each line"-------------•---------------Width of tree ch. Type of filter material-------------------------Depth of filter material-----------------------Total length'---------------•-------- ---------- -- Seepage Pit: Distance to nearest well-.___.___-_x-__":__Distance from f undation�� ..Dis#ante to nearest lot l e" Number of pits-_..__-__/____-_____Lining material____ _ _ ._ Size:'Diameter__- _��..-.__Depth_" "��"�----�--- { r� , I Cesspool: Distance from nearest well------------------Distance from foundation-_-.--------------- Lining material_.-.____�^_______.-_. _ t ❑ Size: Diameter = = Depth -----------------------------------Liquid Capacity------------- . -""Distance from nearest building Privy: Distance from nearest-well-- ----------- ---- ------- ---------- 94-------- -------------------- ------ ❑ Distance to nearest lot line.– ------'--------------------------------------------- ----- - .. ----- - ----"`"'-=------ ----------- Remodeling and/or repairing {describey:-_-_ _ ^. *� -- --------- ------ ----=----------- ----------------------- --------------------------------------------------------` =-------- -----=------- ------•--------"------•--------------------------------------------- -------------------- 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. (Si. ned} A/_,Z '�'�...../ _._ - (Owner and/or Contractor) /r __ � -- ------------------------•----------------•-•------------------------------{Title)_. B . X.rilG�[tS - Pe/[ C��t.. ---.--. (Plot plan, showing ,`location of system in relation to wells, buildings, etc., can be placed on reverse sid . t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- ------�- -- -- -•---------------------------------------- DATE------ -------- sf------------- .... DATE------ --------REVIEWED BY - , BUILDING PERMIT ISSUED---------------------------------- ------------------ -- ----------- DATE :------------ -------------------- Altera+ions a d/or recommend atons:----1�y--- f6�-- -,� '4u ��_--- ----- � `v ------------ ----------------- -------------------------------------------------------------- ---- T _ . ., Y=S ------------------- ----- ------ --- - ------------------------------------------------- ----------------------------------- _ - f - -------------_---- FINAL INSPECTION BY:.. �1^f/1.� l' ..,,. Date f a'= s SAN JOAQUIN LOCAL HEALTH DISTRIC 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised )-57 F.P.CO.