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APPLICATION FO NITATION PERMIT Permit No. ... ,_............ <br /> (Complete in Duplicate) <br /> Date Issued ---./r-7� <br /> /z---_- <br /> jWpplica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> is application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS A ,n0CAdA <br /> TION--- .....0 -------------------------------•-----------------------------•--------------- --------- <br /> / ....... <br /> Owner's Name ••.�.. •� ----• - <br /> • --------------------------------------------- --------------------------------------- Phons --G <br /> Address--------- A ...... <br /> - <br /> Contractor's Name....— &.&;k---------------------------------------------------------------------..------------------------------------------. <br /> Phoned-©.- � <br /> Installation will serve: Residence (Apartment House ❑ Commercial ❑ Trailer Court ❑ /Motel ❑ Other [INumber of living units: __-1.-_ Number of bedrooms _3-__ Number of baths .V..... Lot size __1r'_........................Q� <br /> ------------------------ <br /> Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ly Vft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay F] Adobe Hardpan E] Ch <br /> Previous Application Made: Yes E] No E!r New Construction: 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 /> Disposal Fi Id: Distance from nearest well---__-________-_Distance from foundation....................Distance to nearest lot Fine................. .04 <br /> Number of lines___________________________________Length of each line................._------------Width of trench......__-•-_-___•___-______________ <br /> Type of filter material_______ _________________Depth of filter material----.-_--___•_.________Total length................................_......... <br /> Seeps Pit: Distance to nearest well___ alQ-------Distance from foundation__ pot- y,_.�stance to nearest lot Lne lb.1 <br /> Number of pits__1------------------Lining material__*t-—___ p '" %°- <br /> ------.Size: Diam ter----- -0-------------Depth --...--• �'----'�" -•- <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material------------------------------_....... <br /> 0 ❑ Size: Diameter---- --------------------- Depth -------------- ---------Liquid Capacity-------------------------_-gals. <br /> Privy: Distance from nearest well______ _- --------------------------------------Distance from nearest building------------.____________•_•_____________- <br /> ❑ Distance to nearest lot line------------- -----•-----------•--------•-•---------------`------------- --,---�------------------------•-----.-----•------•----•---------------- <br /> Re odeling and/or repairing (describe):-____------ '_ _____ -�r�t-"- �i-��; �ts ----- A-��+n.}----T1!----- <br /> (� <br /> ....... . ---------------------------------------------------------------------------------------------b----------------------------------------------------------------------------------­------­----- <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, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) -- (Owner and/or Contractor) <br /> By:- <br /> •--•••--• • - . • • . (Title) n <br /> (Plot plan, showing si of Z��nof system in relation to wells, buildings, etc., can be placed on(Feverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------.--------------- ............................ DATE._...._...__._ __._____ <br /> REVIEWED BY. -- :_:.. DATE p-- ...._ t <br /> BUILDINGPERMIT ISSUED..............................• -----•.......•. ••-• DATE--------------------------------------------- ............... <br /> Alterations and/or recommendations:----------- --------- -------------•-------•-------------•--------------------............... <br /> .............................-••-----•------------•--•------•----....•-----------•------------•---....••••---•••••••••--•••-•--------•--••-•----•-•••--•-•••--••----•--•.._..--•----•--••-••-------------•-•--•--••-••----•-- <br /> ----------------------------------------------------------------------------------.......................................................................................................................................... <br /> .........................................------------------------------------------------ -----/4� .........-----------------------------•-•-----•---------------------------- ......................... <br /> �-- �/ <br /> *FINAL INSPECTION BY: �'� ... 7 ' ' `? _"' Date 7--------------------�---------------------------- ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Strest 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 />