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FOR OFFICE USE: 103 ______-___-...___. - -. APPLICATION FOR CATION PERMIT Permit No. ........................ --------------------� -------------------- (Complete in Duplicate) Date Issued /.y_/ 6� ------------------------------------------------------ This Permit Expires 1 Year From Date Issued Application 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 compl}ar"gith County Ordinance No. 549. /V)f�1jTFCPj mf 11 JJ (0 J y JOB ADDRESS AND LOCk-- Addres! N_..._�(JS7!------ --------- -----------" I-IS � � �r�ZCI Owner's Name------------------- - (_!/l.A N fir) C-�= `Phone-- --' -----I---_----_--13 QAC----- 1`� 7 A-'---M9617I-�--=--=-----------•---•--•---------•------•--------•---•---•- ..._.. /�l�P ��NE e �/ /p �,f� �y-� �ry Gam, Contractor's ame /�✓�/V ,f* 'T//✓/��` /'/ +' Phone�l-L' ✓�---�C !� Installation will serve: Residence F( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ E]Other �\ Number of living units: -------- Number of bedrooms __ Number of baths . Lot size __ /1-- -��.__��____________________________________ 1`y� Water Supply: Public system ❑ Community system ❑ Privatex Depth to Water Table /0_ ft. Character of soil to a depth of 3 feet: Sand y Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------- ---------_) Nox New Construction: Yes No ❑ FHA/VA: Yes E] No E]TYPE OF INSTALLATION AND SPECIFICATIONS: - (No septic tank or cesspool permitted if public sewer is available within 200 feet. Septic Tank: Distance from nearest well---5` -----Distance from fo ndation_R!�----------Materipl_..C.,. -------- --- a n No. of compartments..._-_-__.�__.__-__-Size_, � ..........Liquid depth._____--------------Capacity. Qo + Disposal Field: Distance from nearest well----6Distaifm foundation....43-5........Distance to nearest lot iine__'�..._._.__. Dumber of lines.________,1----------------------Length of each line__3� �5,J__y_U.Width of trench--__x�--__ Type of filter mate ria l__-0_Cit----.__Depth of filter materiZ .^,�'�otal length_____L. ----------------_---- Seepage j._.----.--•._-_ Seepage Pit: Distance to nearest well-------------__-------Distance from foundation....................Distance to nearest lot line-_.____.___-___-_ ❑ Number of pits...------------------Lining material------------.----------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well--------------...Distance from foundation-----------.--------Lining material._---------------------------------- F1 ------------------- --❑ Size: Diameter------------------- ---------------Depth--------------------------------------- ----------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------....._Distance from nearest building------------------------------------------ 17_1 -_._-_.--__-__-__-_..____._..- ___.-.❑ Distance to nearest lot line -- --------------- --------------------- ----------------------------------------------------------•--------------------------------,- Remodelingand/or repairing (describe):-------------------------------------------------------------------------•-•-------------------------•--------•--•--•---------------------------------- -------------•---------------•--------------------------------•--------------------- -------------------------•-------------------------------------------------------------------•---------------------------------------- --------------------------•----------------------------------•---------------•------------------------•----------------------------------•-------------------------•-------•-----------------------------------•------------ I hereby certify that I have prepared this application and that the work will be dont in accordance with San Joaquin County ordinances, SK;u d rules a d regulations of the San Joaquin Local Health District. (Signed)--------- - ---- = - w (Owner and/or Contractor) By:---------------------------------------------------------------------------------------------------------- ----------------- -------(Title)------------------------------------------ - ------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ------- -------------------------------- ------ DATE-.---- ------------- ---------------- REVIEWED BY--------------------------------------------- ------ -------- DATE---- - BUILDING PERMIT ISSUED------------_------------- DATE. ------------------------------: Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- ----------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------•-- ----------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------- -•------------ ------ ------------ ------- --------- --------------------------- ------------- --------------------- -------------------------'-------- ------------- FINAL INSPECTION BY:- --------Q vv/'( Date--------- '1 _'_�. ------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.co.