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FOR OFFICE USE:, , --------------------------------------------------------- --------------------------------- APPLICATION FOR S*Nl`TA1,I0N PERMIT Permit No. p-- - --------_------------------------------------------ -- (Complete in Duplicate) Date Issued 1¢�-_ _/- -__.._-----------------_-_--_------_._--_-.---.--.--. 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 complian with County Ordinance No. 549. A7-f JOB ADDRESS AND LOCATI �vim- �(f3-F't! �_1.. / �'' = f <.. i / C ---�ha......11 � . OwnersName------------------------- � F '------•----r__�.--------•Ccj---------------------------------------------------- Phone------------------------------------ Address . --..= ------- 6 x c5_.L�J � ------------- Contractor's Name------(_=.WN.1=----R�----------•----•------------------------------------------- ------ --------------------------------••---- Phone................................... Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer -Gew Motel ❑ Other ❑ Number of living units: ----- Number of bedrooms ---L- Number of baths __(___ Lot sizeE_ ---______ Water Supply: Public system F] Community system ElPrivate [JDepth 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--------------------) No New Construction: Yes [- No [4' FHA/VA: Yes ❑ 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 5 '?---.--Distance from foundation----/U_--------Material.. CCtV _ T _ -_--- '� c v, No. of compartments_--. __---------Size___✓.___ `� __,_._Liquid depth.... .._x____------Capacity �f.............. Disposal Field: Distance from nearest _---Distance from foundation----1r -------- Distance to nearest lot Number of lines---------- ---- ----------------Length of each line-----./ _6--------------Width of trench__ -----:�,'1�___-._---------material----- Total length-------------------- Seepage Pit: Distance to nearest well------------ --------Distance from foundation--------------------Distance to nearest lot line----------------- 1771 Number of pits----------------------Lining material-------------.---------Size: Diameter-----------------------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 to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):-------- -------------------------------------------------- -•-----------•---••-------------------------------------------._----------_---------- _. _ _ _ - __ _ _ __ ________________________________________________________________________________________________________________________________________________________________________________ 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)------� - ) I`=----- ------------I----------------------------------------------------------------(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 DEPA MENT USE ONLY APPLICATION ACCEPTED BY-------� C° --------------------------------------------- DATE------ --- REVIEWEDBY----- -----------------------------------------___-------------- ------ ---------------------------------------------------- DATE.---------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------•-------------•--_-------------------------------------- DATE----------------------------------------------------------- Alterations and/or recommendations----------------------------- --------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------- ------------------------ ------- ------ --- - ----- --------- --------------------------------------------------------------------------- FINAL INSPECTION BY; `�' %��11:11;- -- .I Date--------------------/ � _ -------- ------ SAN -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.