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APPLICATION FOR�NITATION PERMIT Permit No. -_----_1./�_----- .. (Complete in Duplicate) �J� l Date Issued ----------------------- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. chis application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION----r1XL ' , - - ------------- 1 ` -- `- ------------- ------------------------------------------- -------------------•---------- N �r , - Owner's Name-/_,.V,--t_,", ;_fit<: ----------- ---------- ----- -- ----------------------- Z `y. ! --------- - Phone__ ___�_____. Address----•-��'Sir ---------------------•--•---- � -------------------------------------- ---•-------------•---------------------------•---•------------------•--------------------------- Contractor's Name__. - t-[__ - c 's '---- '''cl W`'4 , t <t, --=------------- Phone----- _-------------•------------- Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms _ __ Number of baths ---/-. Lot size -----' %-----_44c'-t-&_..______________________ Water Supply: Public system ❑ Community system ❑ Private IQ Depth to Water Table __�__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 4 Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes;j No ❑ FHA/VA: 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 well_________________Distance from foundation-------------------Material-----------------------._-____________________._. C%XW_110T No. of compartments-------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- (i'r Disposal Field: Distance from nearest well----------------- from foundation--- i�--_____Distance to nearest lot-line__-?.____. C ' Number of lines-----------------/---------------Length of each line-------_l�?r¢ �Wic of trench,---------- ��----__------ Type of filter mate ria 1__� -------Depth of filter material_____ tali length_-__-_-:_.Z�_'^__'�______________ `( eepage.PtDt: Distance to near t ell_____ ____ _______Dis nce from fou a ion'��!-_: 1 Mance to n st lot li y� ® Number of pi _._-___-- Linin aterial _ 5iz �i er_�� ept ---- -------------------------- L�, rCesspool: 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-------------------------------------------------------------------------------------------------------------------------------------- � Remodeli g and/or repairing (describe):-- •-- -•-••• �_`_': -----•------------- ------------ L -------------------------- -------------------------------=---------------------------------------------------------------------•--------------------------------------------------- ---------------------------------------------------I---------------- ----------------------------------------••--------------------------------------------------------------------- -------- ------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S ate laws, and rules and regulations of the San Joaquin Local Health District. {Si ned r F g '---__---- ----s� "- �c� ��-_,,��.!--'------_--_-- --(Owner and/or Contractor) By:--- ------------ --- '{----------------------------------------------------------------------------- ( } ��-------------------------- (Plot plan, showing s of lot,. of system in relation to wells, buildings, etc., can be placed on reversegde). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------- ------------------------ - ----- .---------------------------------------- DATE------------ 7----- - /- �- { 1------------------ REVIEWED BY-------------------------- ---------------- - --- ----- ------------------------------------------ --------------- DATE---------------------- -- -------------------------------- BUILDINGPERMIT ISSUED------------------------------------ w DATE------------------------------------------------------------- Alterationsand/or recommendations---------------------------------------------- ----------•-------------------------------------•-•----------------------------------------------••------------- --------------------------------------------------••------------------•----------------------------------- ----------------------------------------------------------•--------------------•----------------------------------- -------•---------------------------------------------------•------------------------------------------------------------------------------------------•----------------------------------------•------------------------------ -------------------------------------------------------------------- ------- --- - - - FINAL INSPECTION BY: 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 ES-9-2M Revises }-37 FY.CO.