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CltiD� liate) Permit No.Date Issued - ---- � APPLICATION FOR _ ,NITATION PERMIT [Complete n Duplicate) `J` $S� -- --- ---;--_-- A plication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. . }his application is made in compliance with County Ordinance No. 549. JOB ADDRESS A D L ATION - - ---fd ' : -� -•------=------------ -- 1 Ph i Owner's Na ------ ----- Address_ ------------•-- - ------��-- -� -- ---------------------- ------ -------=---------------••--=----------------------------------------•-------- ------------------------ ------------------------ Contractor`s Name------- y�� -------------- ---------------------±--- PhoneOr_ - J�` Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms -- Number of baths ------- Lot size ---------------- Water Supply: Public':system Community system ❑ Private [I Depth to Water Table 40-- ft. -Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ NoV New Construction: Yesk No ❑ FHA/VA: Yes ❑ No_4�T j Y TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or`cesspool permitted if public sewer is available within 240 feet.) Septic Tank: Distance from nearest well----------------- from-foundation--------------------Material------------------------------------_____________ No. of compartments-------------------------Size--------------------------------Liquid depth--------------------------Capacity------------------- i Disposal ieid:/ D7s a �i_: - -EE' o-rrearpin� -..- - _ le .eachine'"�"_ � V�ic�f1i of� r { ----- �� ` r Type o ---------- --- ------------- p l Seepage:Pi+: Distance to nearest well=____ 1�_______._Distance from f undation__l____ _______Disfiance to neares lot. e_____ _.____ Number of pits. _Size:material_ __ __-- __-_.__.Size: Diameter:___ _ .____Depth ----- ---------------------- Cesspol: Distance from nearest well-----------------Distance from foundation---_----------_-----Lining materia------- -- --------------------------- ❑ Size: Diameter -- ----------------------------------Liquid Capacity-- -gals. Depth (i Privy: Distance from nearest well--------- --------------- ---- -___________Distance from nearest building------------------------------ --..._. Distance fo nearest lot line---------- --------- - ----------- - ------------------- -------------------------- M Remodeling and/or repairing (describe) er --------- ;; --- --- -- ---- ------- - --------- --------- -- - - ------ ------------ --------------------------------------------- ----------------- --- I hereby certify that I have prepared this application and that t e work will be done in accordance with San Joa din Co y ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. sL, ---------:----- ------------------------------------------ - --------------------------------------------------- -- --------(Own r and/or Contractor) �! (Signed)---__ BY= =. = --- --------------------------------------------------------------------------------------------------(Title)- -- - --- -------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on rev_ se side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------- ------ - --------------------------------------------------------- DATE-------- ------------ - --------------------------- REVIEWEDBY------------------------------------------- --- - -------------------------------:---------------------------- DATE----- BUILDING PERMIT ISSUED------------------------- -- ------------- ---- -------- D E----------{---- - - Iteration and�ar recom a atio ------------- ---------Tr_77__ _- `= --------- ------------------------- �, S`+- ,FINAL INSPECTION BY--------------------- - ---- -- - •- ------------ Date ------------ ------ ------------------------------------- ' � 9 r ,A S JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street - 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California ( 1W-Aiq0,9 Lodi, California t /$ �uManteca, Californib Trecy, California ( ES 2M/- 'R�vised 1'57 F,�CO: •`