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V� 5\` �,APPLICATION FOR41NITATION PERMIT Permit No. _.c1.7�1d........ (Complete in Duplicate) s () ��. Date Issued pplication is hereby made to the San Joaquin Local Health District or ermit to construct and install the work herein described. q � e es ed. his application is made in compliance with County Ordinance No. 9 - JOB ADDRESS AND ATION.... .........!j _ .....___.. -._-_ Owner's Name.- --------- _A----- Ph one Address..............fir .. -- .- .... ... Contractor's Name.... __. / /// - Phone yp f. 2Cl!"_wc'-y-------•-- - ------ •------ sem`----'• - ✓ Installation will serve: Residence Apartment House mercial ❑ Trailer Court ❑ Motel Other ❑ _ Number of living unit umber of bedrooms umber of baths ,� --:. Lot size �� __- •��--•--•--•-•------••-- Water SuPPI • Publics stem Community system ❑ PrivaDepth 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: Yes ❑ N;4 New Construction: Ye No E] FHA/VA: Yes ❑ No \ TYPE OF INSTALLATION AND SPEICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) posalDistance from nearest well_________________Distance from foundation....................Material__•_-_-._-______- •..-_......................... No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity--------------------•-- d 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.............._...__.._...._..__._...-__.Distance to nearest well-i.2�'._.._.Distance from undation Dist Ve to nearest lot lin re- Number of pits ---- ------ Lining materia), Size: Dia eter__a - ,Depth—. _ .._. 0 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 d/or repairing (describ r-.--•- -- --- --- - - ---- -- ------•----- -- ----- -- . --------- •-_.. .. -- . -------------- ------------------------ -------------------------------------------------------------------------------------------------------------------------------...... I h reby certify A have prepared this application and that the work will be done in accordance with San Joaquin Coun ` ordinances, State law n rules egulations a San Joaquin Local Health District. (Signed)--------------------- ..... - ------------------------------------------------------------ --------- ---(Owner a /or Contractor) By: -----------------------••----------------- (Titl L (Plot plan, showing size of lot, location f system in relation to wells, buildings, etc., can be pl d on rev•.rse s• e). FOR DEPARTMENT USE O LY APPLICATION ACCEPTED BY--- --- ----------- ------ ------------------ DATE----------- �1 REVIEWED BY ----- -- -- ------- -------- DATE--------- {� --•--- BUILDING PERMIT ISSUED------------- --------------------- ------------------— --------------- DATE. Alterations and/or recommendations: -----------=--------------•-- •-----------------• ••--•-----------------•-••. -----------------=- - ------ . --------- �r---------- -- . - ------ --------- - -- - ---------------- .... --------------------------------------------------------- r'Z "b -cJ --------•--- ------ •-- ------- 10FINAL INSPECTION BY:... . ---•----. Date---- '"- `- •------------ l , SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 4614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 P.P:CO.