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APPLICATION FAANITATION PERMIT Permit No. ._.. ..7.g�... \ (Complete in Duplicate) S �0 Date Issued ----.__.l`.-`�,--'- Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AN LOCATION............ ........... Owner's Name.. A------------ - ----- - ------ •-------- �' Phoneys Addres { -----t-------------------• --- - ... - __ .__. ._..-_ _ _A____.1__ _.__._ - ...._. ..... .._... Contractor' Name._-----_ ArC-• -� y-------- �= 4 -----------------------I--------------------------- ----------- Phone Installation will serve: Residence^ Ape' ent House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: __ . Number of bedrooms _Z Number of baths ./-/.__ Lot size ..... •_.. Water Supply: Public system Community system ❑ Private ❑ Depth to Water TablA4/2�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ Nox New Construction: Yes No ❑' FHA/VA:Yes ❑ 7 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic nk: Distance from nearest well-----------------Distance from foundation---.................Material-------------- ............. No. of compartments--------------------------Size----------------- -------------Liquid depth-- -------- --------Capacity---------------------- isposal F' d: 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-_--------------- -- tal length------------------....................... Seepa et: Distance to nearest wel .Distance from undatio Dist a to nearest I t in Number of pits--- _-_---___-Lining ma#erial L-_-_--Size: Dia eter___C --,.__.Depth_-.-. _- ` %� Cesspool: Distance from nearest well-----------------Distance from foundation-------------------- material-------------------------------------- 0 --__-_-__ _-_- _-___---- ❑ Size: Diameter - Depth --- Liquid Capacity-------- ------•----•--gals. m Privy: Distance from nearest well-------------------------------------------------Distan from nearest building__-••__-_•___---____-.•-___-_-.---..__- . \ ❑ Distance to nearest lot line---- ----------- ----- Remodeling and or repai ing (describe):-_-- _ ------ -••-•-•..................................................--•---•--•••-- ----- •. ---•----- .................................. ••....•- ----------------------............................................................. ----------------- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County dinances, St ws, a rul and r ns of the San Joaquin Local Health District. (Signed) 96` -�-- ------- ----- ----- ------------------ -------- - .(Owner an /or Contractor) -- --- --- Y' -- ------- --- ---�------ - - - -------- - -------- -- -- ----=--- (Plot plan, showing size of to , location of system in relation to wells, buildings, etc., can be p ac d on revere si FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- •� ------- ------ ----- -------------------- DATE------------------------------- REVIEWEDBY------------------------------------------------------------------- --. DATE BUILDING PERMIT ISSUED------------------------------------. . --- . --- ---------------------------- ---------- DATE..................... Alterations and/or recommendations - . --- ...................................................................... i-_.-. •------- -------------------- --- ----- -- ------------ ---- --------------------------- .----- ��' ---- ..-.. ------- - ...................................................................... ------ 's ----------- -------- -- FINAL INSPECTION BY:. Date •-<-=----- --- ------------------------------------- SAN -------•--------- - ----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 1.57 F.P.CO.