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APPLICATION FOR .ANITATION PERMIT "Permit`-No- ___ -"3 3-5 <br /> (Complete in Duplicate) Datem.Issued --- <br /> A pliicalion <br /> -Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS A LOCATION-__��_�_--�--15__.:-_ .................... <br /> Owner's Name - <br /> t `; 1�-------- -------•------------------------:--' - Phone ,! <br /> :w. _ . .-----------------------_ _ -._ <br /> Address ...-•- -,--- ....................---------------------------------------------------------------- ... - - <br /> Contractor's Name -'-e-----------------"-----------------------=------•-------•---------------------•"------------ Phon ----- �=1_ <br /> Installation will.:serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ <br /> Number of living units: ----f-- Number of bedrooms __` . Number of baths ---1_1 Lot size -__ �_/._ �-_-------_ _ <br /> - -_-_--_--__ <br /> Water Supply: Public system ❑ mmunity system [-] Private [-] Depth to'Water Table_ ff.—Character of soil to a depth of 3 f_Cc <br /> et: :Sand El -Gravel ElSandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [�Hardpan ❑ <br /> Previous Application Made: Yes No"�w Construction: Yes ["No El <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> ic " <br /> Septanke Distance from nearest well-----------------Distance from foundation_--------:__---_-_.Material ---.___-_-----_--_--.--".-_---_._-_-__--_._. <br /> Nc�-of conipartmen -------------------------- ----- <br /> tsSizeLiquid depth.--------------------------Capacity-_-------------------- <br /> _ -------------------------.. , . <br /> Dispos i Disiance-from,nearest well L________________Distance from foundation.._-_--:__-_--P-----Distance to nearest lot line_---__-_..-__---- <br /> ' Number. of lines--------------------------'--,-----Length of each line------------------------------Width of trench---------. ------------------------ <br /> Type of-,filter material------------------------Depth of r aterial----------- :-----Total length------------------------------------------ <br /> S <br /> it: Distance to nearest well_ ------- - Grp ;, _-._.--- <br /> Number of.pits.__.'L_.________.Lining materi ze: 'Diameter._.-� _ _:----.Depth___ _________________ <br /> Cesspool: Distance from.nearest well-----------------Distan fr ndation--------------------Lining <br /> - material-------------------------------------- <br /> Ell----------------- ------------------. <br /> ❑ Size: Diamefer---------------------- ------De th------------- = ---Liquid Capacity ---------- gals. <br /> Privy: Distance from nearest well------------------------------------------------Distance from nearest building------------------------------- ----- --- <br /> ❑ -Distance to nearest':lot line-------------------------------------- ----------••-------- ------=---- - <br /> Remodeling and/or repairing '{describe):.-- --f- - ------ $---=- <br /> . L1 <br /> ----- ----------------- ­-----------------i------- <br /> I hereby certify that I have prepared this application and that the work will-be done in accordance with San,Joaquin County <br /> ordina ate laws, and rules-and-regulations of the'San Joaquin Local Health District. <br /> j i <br /> (Signed). --••------ ------- ------------------------------------------------------------------------------------ _ 'and/or Contractor) <br /> By--------- ----- -- ---=-- ------ mo o.. -----------------------------= = (Title} Wn -------------------- <br /> (Plot plan, showing ze of , location of system in relation to wells, buildings, etc., can be placed on reverse side) <br /> FOR DEPARTMENT USE ONLY F <br /> APPLICATION ACCEPTED BY__- ---___-`- _ -- •' r X ----f-- DATE_Z _--------------------- <br /> ------------------------ _ ------------------------- <br /> REVIEWED BY------------------------------ =•----------------------1------- ------ DATE <br /> BUILDING PERMIT ISSUED- J-----�j - � � 1� <br /> --------------- ATE- ------------- <br /> Alterations <br /> ------Alterations and/or recommendations----- ------------------= '---------------------------:.__---------•---=-------------•- <br /> - - <br /> -------------------------- ----------------------------------------------------------------- <br /> S <br /> ----------------------------------------------------------- <br /> _---_____._--`----------------------"--- ------------------------------------------- <br /> ----..---------------.------------------------------------------- <br /> •----------------------------------------------------•------.._------_------------------------ <br /> f <br /> FINAL INSPECTION BY::___- ------ ------------------------- ------ Date__.1--------------- -- ----- <br /> -^_---------' ' -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES--9-2M ; Revised W-2100 <br />