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FOR OFFICE USE: t ---------------------- APPLICATION FOR"SXMITATION PERMIT Permit No. _�e..... � ---------------- -------------------- ------------------ (Complete in Duplicate) Date issued --------------------------------- - --- 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 Ord' ante No. 549. JOB ADDRESS ANP,LOCATION---- ----- --- ---------•------•--- -------------------------------------------------------------- Owner's Name- - -- -'-� '_---_..- --- ----------------------- ------ ---------------'---------- ---------- Phone..------------------------------•- s Addressa:._ - -----------------------------------•-----------------------•--•-----•-•-----•--------------- Contractor's Name----- -•---• --------------------------------------------------------•----•----------------- ,..:_: ------------------------ ----------------•--- Phone---------_.----•--•---------------- Installation will serve: Residence [l}!Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel p Other ❑ Number of living units: ___j-.-- Number of bedrooms _-._ Number of baths Lot:size3-&-,?-------------------------- Water Supply: Public system ®Community system ❑ Private ❑ Depth to Water Table �7.�.4_ ft Character of soil to a depth of 3 feet: Sand ❑ G+avel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 'Hardpan ❑ Previous Application Made: (If yes,cla— ----------------- ) No ['� New Construction: Yes �No ❑ FHA/VA: Yes ❑ No El'' � TYPE OF INSTALLATION AND SPECIFICATIONS: ' _ (No septic tank.or cesspool perF itted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest well-----------------Distance from foundation/()-------------.Material---..(_`X. �r..._.___.__. No. of com artm , f p encs------2---------------Size--------3--�-j--X-�f_Liquid depth-------"1r - Capacity--- . Disposal Field: Distance from nearest well__ ........Distance from foundation�4�....r__......Distance to nearest lot line_; --------_-`� [ Number of lines---.-19----------------------------Length of each line-__75"'.................Width of trench..,2.. --`----_---------.--- Type of filter material-----11 0-C-k--.-_-Depth of filter material__—/Y.............Total length--_�yti-zJ__=____________________._ Seepage Pit: Distance to nearest well-- -------------Distance from foundation/ ta.._--______.Distant i to nearest lot line_�5:.`__.___.._ Number of pits---j--__.._._.__Lining material _ p_ ._4C.Size: Diameter _;33 Depth------2:L%)----__._____.__. Cesspool: Distance from nearest well-----------------Distance from foundation-------------- ___Lining material-------------------------------------- f q ElSize: Diameter--------------------------- ------ ----Depth__.------------------------ ---------------------Liquid Capacity----------------------------gals. V Privy: Distance from nearest well- -----------------------------------------------Distance from nearest buiiding._________.___._.-_----__---_-__----..._. ❑ Distance to-nearest lot line--------- ------------ "'•- -=------ =------------------------------------------------------------------------------------------------- O f Remodeling and/or repairing (describ ):--------- -------------------------------- ;-----------------------•--------------=••---------•-------•-------------------------------------------.--. , ---•-----------------------------------I--------------------------I------------------------ --------------------•--r----------------------------------------------------------------------------------------------- -------- --------------------------------------)--------- -----------------I----- --- -•---•-------------------------------- ---------------------------------------------------------------------- ---- ---- hereby certify th ave prepared this�pplication and th� t ---------- --------------------------------- ------------------- t the work will be done in accordance with San Joaquin County ordinances, State ia>� , nd sand`re ui ns f the San a uin local,Health District. � k (Signed)-------- - -- --------- ------------ --- --- ---- -------- ------ ------------------------- ----------------=---------------------{Owner and/or Contractorl BY ------------------------------------------------------------------------------- t (Title)--- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY-----=--- ---- ----------- -----------------------------------------=--------------- DATE--- L°:Co: f-------- --------------------------- REVIEWEDBY-------------------------------------------------------- --------------------------------------------e--------- -• -•. DATE------------------------------------ BUILDING PERMIT ISSUED-----------------=---------------- --------------------------------------------------- --- DATE Alterations and/or recommendations: t�� i3.1�----�-= -- -----------------------••--------•--------------------------------------- r F I ______________ i I l 3 FINAL INSPECTION BY: �, t ... 'f 3 - Date 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.Q Q.