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FOR OFFICE USE: 43 APPLICATION F ° ,S _ ITATION PERMIT Permit No. (Complete in Duplicate) Date Issued -----7 ------------------ -- ---------------- ., . 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 compliance with County Ordinance No. 549. C;7 AV i r-- ------------------------ �j s JOB ADDRESS A LO RN � � r ---- -_---•--------- Owner's Name----- ----- r C --- ---- --- --- --- r_ Phone--- S`� F _�.__....__ ------ - . -•- -- - �a�-- --- Address---------- --- 1 Contractor's Name-------_----- ----------I------------ - -- ----- Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ •----•----------------------- 1 f Number of Living units: ___.___-.Number of bedrooms --------_ Number of baths -------- Lot size _______________________ . Water Supply: Public.system ❑ Community system ❑ Private ❑ Depth to Water Table -____,__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes date-------- -----------I No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet.) Se • ank: Distance from nearest well_________________Distance from foundation-------------------Material_______-_____----___._---------------------- ❑ -----Size----------------- --Li Liquid de th----------- --------------Capacity..----- ----------•---- No. of compartments_______________ --------- q P. � �.► isposal 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------------------------------------------- See ge Pit: Distance to nearest well-----------------------Distance from foundation_________-_-__;____.Distance to nearest lot line--------------- Z Number of pits------ ------- -----Lining material--------------- -----Size: Diameter--------------------- Depth-------------------------------- --------------------- ool: Distance from nearest well-----------------Distance from foundation------------------- Lining materia4___,._________.___-_______ ___.-___._. ❑ Size: Diameter-------------------------- - Depth-------------------- ----------------Liquid Capacity--------------------= --gals. Priv Distance from nearest well--------------- --------------------------------Distance from nearest building------------------------------------------ A Distance to nearest lot line.- - ---- ----------------------------- r ___________ -------- ------ ___ _ W_____ ___________________________•__________-__ C Re deling and/or repairing (describe):----------- �--- --- G •----------- --•- - --- -- --- - -- - - ---------------- _ - --------------------------------- - -- ------- -- --- ----- j i hereby certify that I have prepared this application.and that the wo will a done in accordance wit San Joaquin County I ordinances, State laws d rules and regulations of th San Joaquin Local Health District. . --- - ________________.(Owner and/or Contracfiorl (Signed)- BY� -----------------=-----------------------(Titl ------------------ - e (Plot plan, showing size of lot, location of system in relation to wells,'buildings, etc., can be placed on reverse side). F FOR DEPARTMENT U Efi LY , T`.— Jill APPLICATION ACCEPTED BY------- - -- -L----- ATI=---------- a41 REVIEWEDBY--------------------------------------------- ----------------------------------------------------------- ATE BUILDINGPERMIT ISSUED---------------------------- ---------- -- DATE------------------ ----------- ------------------------------ Alterations and/or recommendations:----0 ---------- ------- ----------- ---------------------•-----------------------•---••--•-----------•------------------------------------------- ', -------------------------------------- f ----------------------------------------------- -----------•------------------------- ------- --------- F _ _________________--------------------------------- ------------------ ------------------------ --- ________________ ___________________________________________________________ i FINAL INSPECTION BY:.----- ------- --- ------------ Date - ... SAN JOAQUIN LOCAL HEALTH DISTRICT i 1601 E.Noxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lpdi__CarfUrnio 1 Manteca,California Tracy,California ., , ES 9 REVISES 6-54 3M 3-'63 F.P.C[]. j f