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APPLICATION FOR NITATION PERMIT Permit No. -_. ""��----•--�-g > ! (Complete in Duplicate) r L - Date Issued ' b made to the San Joaquin Local Health District for a permit to construct and install the work herein described- Applicat�on is hereby q his application is made in compliance' ith County Ordinance o. 549. -� 3 ._ -- JOB ADDRESS Ar D LOCATkON___ -._- - qq" " -- Phone. �` .!-P_ Owners Name- -- = -------- ---- ---------- = Address_... - Ca ------------ --------------- Contractor's Name________________ - gyp--- V----- Phone Installation will serve: Residence tW Apartmen House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-- ❑ / -{- V a Number of living units: _J.. Number of bedrooms --3._ Number of baths ---I""" Lot size ,tet ------X-.-_ ��------------------- -- Water Supply: Public system Community system ❑, Private ❑ Depth to Water Table 4=: ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy loam ❑ Clay Loam ❑ Clay ❑ AdoJ.be ® Hardpan ❑ i Previous Application Made: Yes ❑ . No ;K New Construction: Yes N No ❑ FHA/VA: Yes ❑ No)x ! TYPE OF INSTALLATION AND SPECIFICATIONS: ` (No septic tank or'cesspool permitted if public se er is available within 200 feet.} Septic T nk: Distance from nearest well_-_�Ga 'Distance from faundation___�4 _.-.__L.Material_.___. ---------------------- r — Size --------------Liquid depth ---------------Capacity---------- ------------ No. of compartments Disposal Id: Distance from nearest well------------------Distance from foundation____==__--_F~-"_Distance to nearest lot line----------------- Number of lines----------------------------------Length of each line--------.---------------------Width of trench.---------------------------------- CI �^jg Type of filter material-------------------- Depth of filter material----- Total length----------------------------------------- GG -/KDistancetoWeare ��'GGG __ Distance from f undation:__.Seepage Pit: Distance to nearest well_____. ____ _ ii Size: Diameter--..�- .--------.Depth _ f- ----------------- x E Number of pits------- Lining material--- _ -1.,, \ ________Distance from foundation------------------_Lining material-__.__--------------------------- Cesspool: Distance from nearest well________ __.__-els• ElSi`z•e.::Diameter------------=-------- "Depth---------------------------------- ----------------Liquid Capacity—-------------------------g I - - -------------------------------- Privy: Distance from nearest well---------------------------------------------------Distance from nearest building------------------------------------------ Distance ----------------------------------- ---- ❑ Distance to nearest lot line---------- ----------- ---- ----- Remodeling and/or repairing (describe):--- '""" � --------------------------r ------------------------ ---- � ` --- --- ---- �t O --------------------------- - --- -- -- -------- ----- ------------- -- - -- -- "-------------------------------------------------------------------------------------------------------------------------------------- I hereby cer+ify th-e+----- -- I have p-repared 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 - � ��--- ----- --- �A By: = I (Title} _�i5 ---------------- (Plot plan, s owing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side} FOR DEPARTMENT USE ONLY41 . h u ,, APPLICATION ACCEPTED BY-------- -------- -- -------- - ---------- - DATE --- - ------------ -- � -- ------ ----- _ _ " ..---------------"-___-_-___________._____ J DATE = - - - --- REVIEWED BY------------------------------------------------I --------- ----- --------------------------------------------- •n !!! -- BUILDING PERMIT ISSUED = -L. : -` f----------- ------------------ DATE Alterations and/or recommendations--------------- ---------•------------- ;� ' ----- -- r -/d- ------------------------------------------- --- -- - - ---- --- ---- --- :., i - -------- - .�:.�: ------ ------------ --- - i INSPECTION BY-------------------------------------- SAN ------------�--------- D --- ------------------ - _ = - ------------ i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West OA Street 132 Syeamore Street 914 North "C" Street ' Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revises 1.57 F-P.CO.