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(v 110. 5 APPLICATION FOANITATION PERMIT Permit (Complete in Duplicate) Date Issued Applica4ionll 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. 11 JOB ADDRESS AND^ L-OCATION------ '� '' ' Owner's Name.------Q!�e.•---•---•--•----•• -------------- Phone n lS 6 ---•-----------_-- ------------- --------------------------------- leC --- ---------------- Address---------------- ...�-----------•---•- -------------------------------------------•-----------•---•-----------------------•- �4----------q-------4- Contractor's Name__._____ _ ___ __ _ ________________---------------------------------------------------------- Phon Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other (� > Number of living units: _______ Number of bedrooms -------- Number of baths ........ Lot size _____ N4 �!Q------------------------------------ Water _ ________ __________________ Water Supply: Publics stem �ommunit system ❑ Private Depth to Water Table . _ ft. Y Y Y ❑ P Character of soil to a depth of 3 feet: Sand Gravel E] Sandy LVm � Clay Loam E] Clay ❑ Adobe 2Hardpan,� Previous Application Made: Yes ❑ No New Construction: Yeso ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: Distance from nearest well_________________Distance from foundation...._...............Material-------------------------------------------------- G, No. of compartments--------------------------Size................................Liquid depth---------- --------------Capacity---- ------------ Disposal Field: Distance from nearest well-____-___-_.-_Distance from foundation____________________Distance to nearest lot line................. Number of lines-__ ______________ ________Length of each line------------------------------Width of trench_................................... Type of filter material________________________Depth of filter material----------------------- length________ ........................... Seepage Pit: Distance to nearewell _ IJ_'e__ Distance fro ,foundation- �Q..�Dis ante �o nearest t�i�e S- Number of pits__ ________________Lining materialm—&-l:. .. Size: Diam to __ _ ___ 3(j_.De th___=___ $ p ----------------- Cesspool• Distance from nearest well_________________Distance fro foundation--------------------Lining material-------..__.______________._.._...__. ❑ Size: Diameter------------------------------------,-Depth----------------------------------------------------Liquid Capacity............................gals. Privy: Distance from nearest well-----------------------------------__ _________Distance from nearest building____________-_______ ______-_-_-____._. J ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling nd/ r repairin scribe): • ------ ----- sQ ... ."!u' ------------- ----SSL ----- -------------- I 4--Lti--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).___ Owner and/or Contractor By:........... ---- ----- -----------------(Title) 1�� �R (Plot plan, showing size ot, location of system in relation to wells, buildings, etc., can be placed on reversbl si4 FOR DEPARTMENT USE ONLY 'APPLICATION ACCEPTED BY--_---_---- - _ - -_- _:_--_--- ___________________________ DATE................/.. .__ 1 REVIEWED BY-- - ---------------------- ----- ----- -- -------------------- DATE I• �r ------------ 'APPLICATION BUILDING PERMIT ISSUED --------- -- -� --- AT Alterations and/or recommendations:-------��_-`-��---�---`-� t/ ----°k ' ,� -- a---- -- .......... - - ___-• -------------------------- ---------------------------------------------------- ----------------------------------------------------------------•-----------------------•-----------___------•-------------------------------------------------- ----------•--------•-•-----•--••-•-•---•-------._----•---•---- -------------------------------------•--•---•----•-•••-••--•-••-_..__•--------•-•-•-------••••--•-------•--•----••--••------------------•--•--•-------- FINAL INSPECTION BY:- Date__/� -�� _ � e/__. ------------ ---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California / ES-9-2M Revised W-2100