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4. 1 APPLICATION FONITATION PERMIT Permit No. _. _...._...�f__. (Complete in Duplicate) Date Issued --- L---- .__ jWpplica+ion is ereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. is application is made in compliance with County Ordinance No. 549., ,.II Q JOBADDRESS AND LOCATION...140..... -- -- ----------•--- -------•----•--------------------------•---------••-----•--_-----••------•••-•••----•------.........-------- Owner's Name A. -a...... --- .. Phon-axn Address_.. - �- y Contractor's Name--• -- ---------------------- -----------------------•------------- Phone ... �3 �1 Installation will serve: Residence 2partment House ❑ Commercial ❑ Trailer Court ❑// Motel ❑ Other ❑ Number of living units: ._!----- Number of bedrooms _.Z-. Number of baths ._I.... Lot size ---- _+ _.a.dRa '______________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Q Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes &RI"No ❑ 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_................Distance from foundation....................Material....................................... _____..__. No. of compartments_- -_. Size--------------------------------Liquid depth--------------. . __:_ _ pati Disposal Fiel 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-- -------- ------------------ Seepag Pit: Distance to nearest well-.__-NA-.-_---_-_Distance from foundationDistance to nearest lot lige----10--------- Number of pits 1 Lining material__I!4-Se►� --.Size: Di3 Q" Depth 2*�. Cesspool: Distance from nearest well ___:Distance from foundation _______________Lining material-------------------------------------- Size: _ ____-_.Size: Diameter--------------------------------------Depth----------------------------- ---------------Liquid Capacity------------------------_--gals. Privy: Distance from nearest well-----------------------------_-------------------Distance from nearest building-_.______-__--______-•..._--..-_______-_. ❑ Distance to.nearest lot line---------------- --------------------------- -------------------------------------------------------------------------- ----•-----------------• ---- Remodeling d/: r repainn (describe)------Q`- -------- �-�►+ ----5?►tiA,t feJ .................... n -�. -C_ ------------------------------------ --•-----------•--------•-•-------•------•-•--------•--•------•--------•----------- -_•-------•---------•---•--•--------------------•-----•...---------------------------•------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed).. --- .... -- --------------------------------------------•---------------------------------------------------------------------------(Owner and/or Contractor) By:----------1-- .....--- ---• • - ----------------------------------------- .....................................(Title)--�-r� (Plot plan, showing siz of lot, Iota n of system in relation to wells, buildings, etc., can be placed on Averse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------ - ------ DATE---------s REVIEWED BY ... ------ ------------------- ............. ...... DATE-------- fc� -------------------- BUILDING PERMIT ISSUED...................................... --•--• --...........- •--------•--------..DATE ----------- Q � Alterations and/or recommendations: �--------- --------------•------------------ ------------------------ ---- --------------.- - ij- o •---------- ------ �,, 'Y` � . --- ----------- ----- -- -- - ..............................------ -------------------------------------- --------------------------------IR r -� FINAL INSPECTION BY:• ----- ----------------•----•.---_----- D'ate....--.------.••-•------------ --•----•--•--•--- .( SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100