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FOR OFFICE USE: <br />------------------------ <br /> APPLICATION FOR SARTATION PERMIT Permit <br /> -----------. - '� J (Complete-in Duplicate) — �� <br />_-. _-_--_-._.� - --- ---- y ___.__.---_- _. This Permit Expires 1 Year From Date Issued Date Issued ./�---_---- <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 AND LOCATION_.,ii 4P—P --- ------------------------------------------------ <br /> 4 <br /> Owner's Name----- <br /> .!LAN_._./51-- -------------------------•---------------------- ------ -- -------------­---------------------- <br /> ------ Phone------------------------------------ <br /> Address------------------ � <br /> -- --`u-'----� -----�-�--�-----------•------ ----------------------------------------------------------- ------------------------------------------- <br /> Contractor's Name - ------------------ Phone--------------------------------- <br /> Installation will serve: Residence f Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [I <br /> Number of living units: I----- Number of bedrooms _,3---- Number of baths I---- Lot size `_rO 4'./43__ ________________________________ <br /> Water-Supply:; Public system El Community system E] �Private. Depth to Water Table P _ ft <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam] Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date-------------- No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material ...--------------------__....................... <br /> ❑ No. of compartments-------- --------------.Size-------------------------------Liquid depth--------- __- ------- Capacity----------------------- <br /> .11 <br /> Disposal Field: Distance from nearest welIXQ.........Distance from foundation.,a)nr__1------Distance to nearest lot line-_5........... <br /> Number of lines__.________ _____ ___-_-_-.---Length of each line___f_- tt_�j' Width of trench.. _Y_'___--___-__--_.._... <br /> Type of filter materiaL��*__-_._.:--..Depth of filter material_-_ _.Z.. '___-._--Total length../_>R____________________________ <br /> Seepage Pit: Distance to nearest well......................Distance from foundation--------------------Distance to nearest lot line----------------- <br /> El Number of pits._ -------------Lining material---------------------- Size: Diameter---------------.-------Depth--.------------------------------ <br /> Cesspool: Distance from nearest well ________________Distance from foundation---------.------- -.Lining material--------------------____._______----. <br /> ❑ Size: Diameter- -- -------------- ---. Depth----------------------------------------------------Liquid Capacity- -------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.----------------------------------------- <br /> F-1 Distance to nearest lot,line_ .-------- ----------------------------•---------------------------- ------------•---------------------------•------------------- <br /> Remodeling and/or repairing (describe):_��t%te "� ytah-------------------------------------------------------- <br /> ------•----------------------------------•------------•---------------------•-------- --------•----------------------------------------•------------------------------------------ ---------------------------- �r <br /> ---------------------------------------------------------- <br /> -----•---------------------------------------•-------------------------------------•--•-----•---------------- --------------------------•-------------------------- <br /> -------------------------------------------•--- ----------- ---------------.---------------------------------------------------------------------------------•--•--...• ------------- ----------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, Tate laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed).i, showing <br /> -- 0,__1--- - - - - ----------------------------------------------------------------------------- ------------(Owner and/or Contractor) <br /> B ---------------------------------_--------- ---------- ...... --------------- -------------------------------------(Title)---------------- -- - ------------------ - ----- <br /> (Plot pla size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ --_. -- -------- ------- ---- ----- -- .-__ ____ DATE.-7)) - <br /> _--- --- <br /> -- <br /> - ----- -------------- - <br /> REVIEWEDBY------------------ ------- ------------------------------_---------------------------------------------------------- DATE------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED---------- ----------------------- --------------------•------------------------- ------------- DATE---------------------------------------------- -------------- <br /> Alterations and/or recommendations------------------ --- ---- ------------- --------------------------------- ------------------------------------------ <br /> ------------ -------------- ------- ---- -------------------- --------------------------------------- -----------------------------------------------------------------------------------------------------.............. <br /> -------------------------- ----------------------------- -------------------- ------------------------------------•---------------------------------------------------------_ --------------------------•-------------- <br /> -------------- ------------- - ---------- ------------ ---------------------- ------- ------------- ---------------------------------------- -- <br /> ------ <br /> U J/ <br /> FINAL INSPECTION BY:.� ------ c ------ Date.-------------------- ? <br /> ------------------------- <br /> a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi. California Manteca,California Tracy,California <br /> E.H.9 2M 1.67 Vanguard Press <br />