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FOR OFFICE USE: <br /> ----------------�- APPLICATION FOR "5ANl7ATION PERMIT Permit No. ___ ......_--3........ <br /> ------------------" <br />----.:---------------------------------------------------- (Complete in Duplicate) _, <br /> Date Issued <br />" ----------------------------------__..........""' --- -This-Permit"'Exvires-'I Year-From-Date-Issued-i-, <br /> ______ <br /> Application is hereby made to the San Joaquin Local Health Distr ct for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. i ) <br /> JOB ADDRESS AND LOCATION__________ _ __2 ./._________ _ _._ <br /> _ ► ! <br /> Owner's Name-------f '--d---------(o--- ------------------------�-A-Jt .__dA--0 .• e`---------- ------ Phone------------------------------------ <br /> I <br /> Address---------------------- ----------- ---------�p- -------- ---------------------------------------------- ------------------------------------------------------------------. <br /> Contractor`s Name----- i------------------------------------- •----•--- Phone- �� 5!27- to- <br /> 7 <br /> : . t <br /> Installation will serve: Residence a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � <br /> Number of livin units: _/----- Number of bedrooms _ Number of baths -/___._ Lot size .___S�6-__`X..-2 o a-------------------------- <br /> Water <br /> -------"------sWater Supply: Public `system 0' Community system ❑ Private ❑ Depth to Water Table -------- ft. + <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 0 Clay Loam'❑ Clay [❑ Adobe [5" Hardpan ❑ �� <br /> Previous Application Made: (If yes,date----------- -------} No [}- New Construction: Yes �3--No ❑ FHA/VA, Yes ❑ No g-- <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: l <br /> (No septic tank-or cesspool permitted if public sewer is available within 200 feet.) t <br /> Septic Tank: Distance from nearest well __.��-------Distance from foundation___________________Material----------------------------------------- --____- <br /> [Lr No. of compartments--------- - - `_? -X14_- _f--Liquid depth-------y- ------------Capacity___♦ b_" <br /> { 7 �. r <br /> Disposal Field: Distance from nearest well._-N-R-----Distance from foundation-------/ <br /> a------- ---Distance to nearest lot nine__S=_._-_____ <br /> Num' ber of lines----------- Length of each line--------`1>y_.-'.-----_I----Width of french------Z-_`------ ------ <br /> Type of filter material-__ '' ______Depth of filter material--14........I_.-Total length---------- 3-_o--__________________ <br /> Seepage Pit: Distance to nearest well---N A______.____Distance from foundation----- _0__­'___.Distance to nearest lot line_-5--____.-.-_ )�f <br /> Number of pits__.-"�_____________Lining material-_'-_6o-"____Size: Diameter-----.31_`_ .___Depth_____2-_5-_f--- -___-_-" C <br /> Cesspool: ,Distance from nearest Weil __.__r----------Distance from foundation__------------------Lining material____.-._----________.___-.___--.___._- <br /> Size: Diameter - - ------- --------# Dept Liquid Capacity gals. <br /> 3 <br /> Privy: "tante from nearest well_____ ______________________+---.________----_Distance from nearest build'rng___--__-"_.________.__________-____-____-. <br /> [j Distance a lot line- " :___�:w.�_�--- ------------------------- <br /> --------------------------- ---- ----------------------------------- <br /> 5 <br /> Remodeling and/or repairing [describe)______________t-_.-*._..__________._ ------------ <br /> -------------------------------------- <br /> 1 <br /> t ---------- ------------------------------------=-------•--•-------------------------------------------------------• r J <br /> ___________________________________.-_-___-_-_-_--____________-_____-______.__.___ ____-__-___.____-_____"__.______________. -------------------------------------------------------------- <br /> --------------------------------------- ________________________________________________________________________________________•__-_______------------------__"______----__ <br /> --------- <br /> -----------------------------_--------------------------------------------------------------------------------------------------------------.-----------------------------------------------------_--------------_----- <br /> I hereby certify that I have prepared+hiss application aand♦lief fhe work will be done in accordance with San Joaquin County <br /> ordinances, State laws,i and rules and regulationsof�an Joaquin Local Health District. <br /> s <br /> (Signed)--------------- - ------ �------'---� ` �rR -------------------------------------=----- --------------------(Owner and/or Contractor) <br /> By:------------------- `-_--------------------------=-----------------------(Title)---------------------------------------- - - - -- - - <br /> (Plot plan, showing size of lot, location of system in-relation to wells,. buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ----- = DATE <br /> REVIEWEDBY---------------------------------- ------ ------------------------------ F ------------- DATE----------------------------------------------------------- <br /> NG PERMIT ISS1UED-------------------- Q T <br /> Alterations and/or recommendatioris:-___ == = I E - <br /> t ; <br /> --------------------- -------------- -- -------- - ------ --------------- - - ---- --- --- -- ------ --- -------------------- --------------------I------ ----------------------------------- -------------------------- <br /> t <br /> -----------------------=-----------------------•-------- -------------------------"-"---"----------------------------------- ----------------------------------------- <br /> - . . � <br /> -------------------- <br /> � ~ <br /> -- Date-----FINAL INSPECTION _ _____ _____� - _ _ r/ <br /> SAN JOAQUIWLO'6 L HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tidcy,California <br /> F.P.CC. <br /> Y <br /> j <br />