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�} 0-J) APPLICATION FOR �1TATION PERMIT Permit No. . �n (Complete in Duplicate) Date Issued --------- ---- --- /.5 S Apphcation is,hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. his applicatiori is made in compliance with County Ordinance No. 549. 30B ADDRESS AND LOCATIO __` --------------- __`___---__,_._ Owner's Name--------Q,-- �� ''` '"a) = ---=---------=---------------=--------------------- Phone-- .�r -�- _ ._, ,... ,.� 77 Address----- --------0 z�$L--------------==----•- --------------------1-------------------------------------------------------------------------------------------t� .`----------✓ -- ContractorsName---------- .J- �.t� --------------------------------=---------------------------- ---- -------------------------=------------------ Phone_-d`r-C•1------------------------ Installation ------ •-•-----Installation will serve: Residence ❑Apartment House ❑ Commercial ❑ Tra"ileri Court ❑ , Motel ❑ Other ❑ ' Number of living units: ___1___- Number of bedrooms _:2-_ Number of baths ___!___ Lot size __r__ __ --------- Water Supply: Public',sysfem'❑�Commun'ity system'El 'Private ❑ Depth to Water Table _ _� ft. Character of soil to a depthof 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ®.Hardpan ❑ Previous Application Made: Yes ❑. No 5j--' New Construction: Yes [g] No ❑ FHA/VA: Yes E] No E TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) = i Septic Tank: Distance from nearest well------ Distance from foundation_____---------------Material______.____________.________________...________-- �>sposal;�FFi�e N .,of compartments----- -----=------------- Size--------------------- --------Liquid depth----------------=---------Capacity----------•----------- d: • =Distance from nearest well________________Distance from foundation--------------------Distance to nearest lot line_______-_______ Number of lines-------------------------------- -Length of each line----------------------- ------Width of french..--------------------- ---------- "Type of filter material-------------------_______Depth of filter material_______.___________Total length_____--:____________._-________--__ � O. r i Seepage Pit: Distance to nearest well_ _.y___Distance from foundation___-_-_-- Distance to nearest lot line_____ Number of pits--- - -------= q - ___Linin materiai___R,tI`-�r�___:Size: Diem Cesspool: Distance from nearest well------------------Distance from foundation___,____---__r_.__Lining material-------------- ___.--------,_-_____. ❑ Size: Diameter_----- ------`---------- -----. Depth----------------------------------------------------Liquid Capacity------------------------ -gals. rivy: Distance from nearest well_'____.__.____b_________________________.'"`Distance from nearest buifding-----------------------------._,___.____- ❑ Distance to nearest lot line =" = -=--------------------------------------------- --- - -------------- --•------------------ -------- Remodeling and/or repairing (descril�e�:_--_ `--- ---__---J------------ -------�--�• -- - -------- ------ - - -- --- - 11 ----------------------•---------------`-----•--------------------------------------------------------------------------------------------------------------------------------------------------------.---------------------------- -------------------------- ------- ------------------------------------------------------------------------------------------ ------------------------=----•-------------•---------•-------------------------------------- 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. i i jct or(Si (Signed) -- -----"-"'-"----- ---- --------------------------------------•------------------------------------------------------- _-------- __(Owner and/or Contra � y � r � --- ------------------------------•----(Title)---- ----------.._..--------------- - BY " " (Plot plan, showing'siAlof lot, location of system in relation to.wells, buildings, etc., can b'e placed on revers side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE _--- REVIEWEDBY------------------------------ - ------------------------------------------------------ DATE-- �----------._.-- A. BUILDINGPERMIT ISSUED....----�J---`-------------------------------------------------------------------------- DATE - -------`---------------- ----------------------- Alter 'on / recom In 'on ' . = ----------------------- -----------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------- ------------------------------- ----- : --- -- .-• Dafe__. ------w- --------------- i +FINAL INSPECTION-BY::�__-� ----------------------------------------- ___________ __ _ - - ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1-57 F.P.CO. r