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FOR OFFICE USE: _-__-_-__-----------------: -- - APPLICATION FOR 5AJITAT1ON PERMIT Permit No. --------------------------------------- --------- --- - (Complete in Duplicate) -------------------------------------------------,---.-.- This Permit Ex ices 1 Year From Date Issued Date Issued . Application is hereby made to the San Joaquin Local Health District for a permit,to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. . JOB ADDRESS AND LOCATION___,/9_0,0__-_-_A __ _. _ t -A,5,0.119 ------------------•---•---•---•--------------------•---------------• - - -- Owners Name------- A$&I----------------------------------------------------------------------------------------- ------ Phone------------------------- Address----------- ----------------------------------------------- Contractor's ---• -----Contractor's Name----------- - ---------------------------- Phone-------------------____ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f Number of living units: __l__ Number of bedrooms _ Number of baths __4__ Lot size Q ____ _________________________ i Water Supply: Public system Community system ❑ Private: ❑ Depth to Water Table 6eft- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe 0��Harclpan ❑ ` Previous Application Made: {If yes,date____________________) No V'New Construction:�Y•es 0 No W;- FHA/VA: Yes ❑ No��f TYPE OF INSTALLATION:AND SPECIFICATIONS: �+ { P P P P � } No septic tank or cesspool permitted if public sewer is available within 200 feet.) sti i Distance nearest wel------------ ----Distance from foundation aterial------------------------------------------------. id deph ,-----------------------Capacity--•-------------------- � W� Noofcompartmetsejqu Disposal Fi Ids- Distance from nearest well__. ._.._Distance from foundation_ _- Distance to nearest lot line__No~-r-- Number of lines___ ________ ength of each line_ _.-_____ 6s Width of trench_ _�____�_____________________ �r Type of filter material-`_ _ __ _ Depth of filter material__ _p._ Total length___ __________________.__._ II � t'J 1 c Distance to nearest well.-------- --_____Distance frgipfo dation ,� _�-_M, rVe to nearest lot Line-JI Number of pits-_./--------------Lining material--- ----Size: Diameter2 .-------- Depth_,;20_-�---_-_----_______-_ Cesspool: 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 -------------------------------------------------- -- Remodeling and/or repairing (describe=------ ----- i �i� ---------------------- ------ ---------------------- ' 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 and regulations of the San Joaquin Local Health District. (Signed)---------- ---------------- --- --'"i".1--1---f�"�------- ---- ---------------------------------------- r Contractor) By:-------------••---------- -- ----- -- -- - Title (Plot plan, showing size of lot, location of sy to relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ------------------- DATE DATE_-- -------------------- ____________________ _____ REVIEWEDBY------ ------------------ ------ --------------------------- ------ DATE------ ----------------------------- ---- -------------- BUILDINGPERMIT ISSUED-------------- ---------------------•---------------------------------- ------------------------------ DATE----------- ------------------------------------------------ Alterations and/or recommendations:------------------ -------- -- ----- ------ - -------------------------------------------------------------------------------------------------•-----------. -------------------------- ---------- ------------------------------------------------------------------------------•-------------------------- ---------------------- ------------------------•-- ----.------------- -----•------------- --•---------------------------------------------------------------------------- -- -------------------- FINAL INSPECTION BY Dat -- --------------------------------------------- -_- SAN JOAQUIN LOCAL HEALTH DISTRICT `' 1401 E.Hazelton Ave: 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California: Lodi,California Manteca,California Trpcyr California F.P.CO.