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1Permit No. .. .--- --CF--�� APPLICATION FOR _,,,..NITATION PERMIT r� /YX (Complete in Duplicate) �/ s� t , Date Issued ______________________ f�pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i his application is made in compliance with County Ordinance No. 549. 4 ------------------------------------- JOB ADDRESS AN CATION-------�--�C�- --� ---Cf---- - -------------- ---------------------------------------------- �1�Owner's Na '__ , "'`i.'~C r a Y Phone Address ---------------------•- Contractor's Name---------- E l - - '- ---------------------------------------------•--------------•--------- Phone '_ X72 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _. ____ Number of bedrooms . .-_ Number of baths _1 ---- Lot size _ _l - r-'------------------ ------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _10-1t. Character of soil to a dep+h of 3 feet: Sand ❑ Gravei ❑ Sandy'Loam ❑ Clay Loam ❑ Clay ❑ AdobeK Hardpan ❑ Previous Application Made: Yes ❑ NOX New Construction: Yes No ❑ FHA/VA: Yes ❑ N TYPE OF INSTALLATION AND SPECIFICATIONS:' (No septic tank or'cesspool permitted if public.sewer is available wi+hin 200 feet.) Septic Tank: Distance from nearest ---Distance from foundation__-/Q_' _ (?- __ ____-Matarial,____ ___ _____________ .:_._. No. of compartments--_,9Size___ ....., __ ____:___Liquid depth______ _ 1 _capacity-----Y�_v_. -------- ---. Disposal Field: Distance from nearest welt------.-_-_____._._D+stance from foundation___________________Distance to nearest lot line----------------- ❑ Number of lines-----------------------------------Length of each line-----------------.-----------.Width of trench.-_-------------------------------- j Type of filter material----------------:--------Depth of filter material-----------------------Total length_------_--_-----------_--------------_-_-- Seepa e.Pit: Distance to nearest weIJ,_-PC_--Z1r-------Distance from undation_A?-----------Distance to nearest lot line----- Number of pits------ -------------Lining material- - --.- --__...Size: Diameter---r _ ___-__--Depth-------- P- ------------ �Cesss❑pool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------------------- _�� Size: Diameter------------- -------- -------------Depth--------------------------------- -----------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well-----------------------------------------------.Distance from nearest building--------------------------------- 0 Distance to nearest lot line._-------_.-----------------m. Op- ------- -- Remodelin- .and/or repair' ri43e�, f�-✓i'__ ' •-----------=-------------------------------------•-------------------------------------------------- ------------------------ -------------------------- ---------------------=------------ ------------------•---------------------------------------- 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 nd regulations of the San Joaquin Local Health District. 'T-- ------------------------------------------- IOwner a d/or Contractor (Signed) t --- By:-------------------------------------------- �� ---------------------------------------------------------------(Title --n..... Plot Ian, showing size of lot, location of system in relation to wells, buildings, efc., can be p ace verse e). ( P g FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY--- ------------------ DATE--------------------------- 4 - - - �. �- ---- REVIEWED BY--.-------------------------==-------------- .. DATE BUILDINGPERMIT ISSUED----------------------- - --- ------ ; ---------------------------------------------- --------- ------ .� Alterations and/or recommendations:. _-- ' ,� r �_ - ----- J ----- - - - --- -- -- --- ---- - ----•-•----------------------------•-------------------------------- �� ' -- ---- ' ' ------ - �� _ '�-�-. 'a r� �� =c: --------------- ----------------------------------------------------- u"_ ----•--------------- -------------------------- ------ ------------------ ---------------------- --------------- ---------------------------------------t tSPECTION BY - Date-------- ------------------------- �` SAN JOAQUIN LOCAL HEALTH DISTRICT an Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street aliiarnie Lodi, California Manteca, California Tracy, California Revised 1-57 F.P,CO.