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FOR OFFICE USE: -- _ - :.7--- ----------------- SA �� - r N --------------------------------------------------------- APPLICATION FOR NITATION PERMIT Permit No. ------------------ (Complete in Duplicate) �. --- - - ---- V � . .. .. ............... ... This permit Expires 1 Year From Date Issued Date issued .cr__- 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 compliance with County Ordinance No. 549. JOB ADDRES ND LOCATION-�---.�0------ -------------------------------------------------- ------------------------------- Owner's Name--- 0_-! u"- - ---• - -- ---------------------------••----...---------------- - -------;------------------------------- Phone------------------------------------- Address-------------- --- Q / --- --------------------------- 4 , Contractor's Name---- ----- .----- -• Phone e Installation will serve: Residence Apartment House ❑qq Commercial ❑ Trailer Court [:] Motel E) Other El Is_ Number of bedrooms -_- ,_ Number of baths -------- Lot size ------�--oL-�_-.X_sO---------------------_...- Number of living units: .... Water Supply: Public system-g* Community system ❑ -Private ❑ Depth to Water Table LA. ft. Character of soil to a depth of 3 feet: t Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Ilf yes,date-Ib___l�'_�3_.) No New Construction: Yes El No [IFHA/VA: Yes E] No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool.permitted if public sewerjs available within 200 feet.) Septic Tank: `Distanca from nearest well-`---------------Distance from foundation--------------------Material---------------------------------- -------------- . ❑ No: of compartments--------------------------Size---------------•---------------.Liquid depth------------ ---------Capacity...-------------------- • s Disposal Field: 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----------------------Total length-------------------------------/--------- Seepage•Pit: Distance to nearest well-------- __-- ---Distance from foundation---10---------- Dist�ce to nearest lot I�e-�.�___-------- R1 Number of pits._.-.1---------------Lining material-- _0.44 __------Size: Diameter___-13.-------..----Depth-° ----------------- --.-- cesspool: Distance from nearest well-------------_-.Distance from foundation--------------------Lining material---------------------------.--- --. ❑ Size: Diameter-------------------------- -----------Depth----------------- ---------------------------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well-----------------------------------------------_Distance from nearest building-------.---------------------------------- Distance _-_- ..-----..._-____------ Distanceto nearest lot line--------------- ------------------- --------------------------------- ----------------------------------------------------------------- { Remodeling and/or repairing (describe}: ------------i-----------------`---------------------------- -----------------------•--------------------------------- -------------------------------------------------------------------------------------------------------------- ---------------------------------------------------- i t — . ------------- -------------------------------------------------------------•---•----------------------------------------------------------------------------------------------------•---------------------------------------- - i :------------------------------------------------------------------------------------------------------ ------------------------------------------ I hereby certify that I have prepared this application and'that the work will be done in accordance with San Joaquin County I ordinances, State laws, an ales�aonsSan Joaquin Local Health District.[Signed} --- -------------------------------------- -------------- (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------- ----- z.---- --------------------- DATE-------- -- ------------------ REVIEWED BY------------------- ------ ------------------ ------------------------------------------------ ---------- ------------------ DATE-----------------------•------------------------------------ ` BUILDING PERMIT ISSUED-------- ------------------ --------------- ------------- ------------------ ------------------------- DATE-------------------------------------------------------------- Alterationsand/or recommendations:----------------- ----------------------------- •--------------------------------------------------•---------------------------------------- ------------------ ------------------------------------- ------------ ---` ------------------------------------- ----------------------------------------------- -------------- --------------------------------------------------------•----------------- --------------------------------------------- ----------------- --------------------------------••---------- ------------------ -----------------• ------------------------------------ --------------------------------------- --------------------------------.-------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:. ..\ ------------- -------- Date ._ . � � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ha:etton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street 4 Stockton,California Lodi, California Manteca,California Tracy,California r.P.cc-