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APPLICATION FOR NITATION PERMIT X10. ____ d.S:__.7S <br /> '� `► (Complete in Duplicate) J�— <br /> ,' Date Issued ---- <br /> Application <br /> __-Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> his application is made in compliance with County Ordinance NO.. 549. <br /> JOB ADDRESS AND OCATION----- ------------------------- --------------- ------------ -----------------------------,-- <br /> - - ----------------------- <br /> Owner'sOwner's Na --- - ------ Phone- -- --:• --'1 �� <br /> Addres ---•-•---• •--- - ------ - ------------ ­- - ------- - --------•-•-. -- ------------------------ - ------•----•......---- <br /> Contractor's Name- -- - ----- ----------- ---I------ Phone - ------ <br /> Installation will serve: Residence( Apart nt House F-1Commercial E] Trailer Court ❑ Motel Other ❑ <br /> Number of living units: _.1-__ Number of bedrooms __/__ Number of baths ___4 Lot size _____ _________________________ <br /> Water Supply: Public system` Community system ❑ Private ❑ Depth to Water Table�� ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob*iP' Hardpan ❑ <br /> Previous Application Made: Yes ❑ No <br /> ,>jr New Construction: Yes)Rf No ❑ FHA/VA: Yes ❑ No�` <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tankor'cesspool permitted if public sewer is available within 200 feet.) ' <br /> GSeptic T nkt Distance from nearest well-----------------Distance from foundation--------------------Material_____-____-___________._---__._--_____-________-. <br /> NoL of compartments----------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- <br /> Dispos F' d: Disitance from nearest well-_______________ istance f foundation-------/-----------Distance to nearest lot life_______---___-__- <br /> G Number of lines--------------------------------- eng -"--:" ..Width of trench-- --------- <br /> Type of filter material-------------------------Dep t of filter m a________--------------Total length-_____--___-•-_-________________._________ <br /> Seepa a Pit: Distance to nearest weld__-_D' ante from o a 'o �/2__`.___;.Distance to nearest lot <br /> Number of pits-----/-------------Lining m erial __ .__ _ _-_.S' . iameter-----,.��Y_______Depth-------- _______-__ I� <br /> Cesspool: Distance from nearest well------------------ istance f undation--------------------Lining material__________________________._________. <br /> ❑ Size: Diameter------------------------- ------------De -----------------------------------------------------Liquid Capacity----------------------------gals. <br /> Priv Distance from nearest well-------------------------------------------------Distance from nearest buildinj <br /> ❑ Distance to nearest lot line------------------------------------------------------ -----------_-•------------------------------------------------------------------ <br /> r <br /> Remodeling and/or repairing (describe):------- ------ - -- ---- -- --- -------------------------------------------------------------' <br /> --------------------------------------------------------------------=-----------------------------------------------------------------4-------------------------------------------------------------------------------------- <br /> --------- ------------------------------------------------------------------------------------------------------••---------------------------------------.-------------------------------------------------------------------- <br /> I hereby certify that I have prepared this applicatien-and that the work will be clone in accordance with San Joaquin County <br /> ordinances, Sta ws, a d r les and regulations of the San Joaquin Local Health District. <br /> (Signed)------- <br /> ----- __________(Owner an /or Contractor) <br /> BY:--_-----------------� ------------------------------------------------------------------------------(Title)---- - ------ - ---_----------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be p ce�verse si <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----TR O.-'-------------------------------------------•-•---------- ------ DATE-------- �-----------------------•------ <br /> REVIEWEDBY--------------#--------------------------------------------------------------------------------------------------------------- DATE-----------------------------------------------------___ <br /> BUILDING <br /> --- ----- <br /> BUILDING PEf MIT ISSUED--------------------------- ----- ------ ------- -- ----------------------------- DATE--------.................................................... <br /> AlterMionsand/or recommendations:--------='------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----- --- -- -- -- / ----- --- ----------------------------------------------------------------------------------------------------------------------- <br /> NW Pir --- RoNi Fr-)CITl_Af .. _� a�t 1�n ----------------------------------------------- � <br /> ----------------—n6T------- ------------4:%-K-- ---------------------------------- 1 <br /> - ------ - --- ------------- ----- - ------- <br /> FINAL, INSPECTIO __ _____ ____ _______ ___ Date_-------- _' <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 , ReviseC 7.57 F.P.CO. <br />