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FOR OFFICE USE: ------------- ------------------------------------ APPLICATION FNITATION PERMITPermit No. l.. l ---------------------- --------- --- - ------- - I------------------------------- ---- ----------- (Complete in Duplicate) Date Issued --------------- ------------_--------------------------- L This Permit ExpiresIll Year From Date Issued 170 -rs 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. e JOB ADDRESS AND LO TIO _Sf ? ._ _D .. � � ice- lF---- C{" Owner's Name------------ --- lqc=k--------Fvt- . - ----------- ---- Phone------------- ----------------- Address------------------ � -� = 'Q --------�' ;---------��-------------•---d�4�--� g Contractor's Name _ l ( -' -----------••--------------------------------------------------------------- -- Phone---------------------------------- Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court ❑ Mote! [:] Other ❑ Number of living units: __j---- Number of bedrooms _�� Number of baths _1--- Lot size __________________________ Water Supply: Public system ElCommunity system ElPrivate eDepth to Water Table _2 ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ S dy Loam El Clay Loam El Clay ❑ Adobe E] Hardpan ❑� e Previous Application Made: (If yes,date____________________) No New Construction: Yes ❑ No 5+1-_'FHA/VA: Yes ❑ No i -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--------------------------Capacity----------------------- Disposal Field: Distance from nearest well-__&Q.-----.Distance from foundation----1_Q---------Distance to nearest lot i fly&- Number of lines---------I--- Length of each line--------�D-------------Width of french.-----1.1---d---- -- -----f----- � ADD Type of filter material.__.9i�__�}- --____Depth of filter material_.____P?-- .-____.Total length--------- a------- Seepage Pit: Distance to nearest welt----------------------Distance from foundation--------------------Distance to nearest lot line----------------- L1 Number of pits--------r-------------Lining material-----------.-----------Size: Diameter.----------------------Depth--------------------------------- Cesspool: Distance from nearest well----------------- from foundation-----------------_.Lining material-------------------------------------- El Size: Diameter--------------------------------- ----Depth------------------------------- - -----------------Liquid Capacity- -------------------------gals. Privy: Distance from nearest well--------------_----------------------------------Distance from nearest building------------------------------------------` ❑ Distance to nearest lot line--------------------------------- ----------------------------------------------------------------------------------------------------- Remodelingand/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, an rule nd regulations of the San Joaquin Local Health District. (Signed)--------- ---------------------------------(Owner and/or Contractor) TK BY= ;--------- ------- --------------------------------------- ----- --------------------------------------(Title)------------------------ ----- ------ - -- - - ---------------- (Plot ----------(Plot plan, showing size of lot, location of system in relation to wells, buildings„etc., can be placed on reverse side). FOR DEPARTMENT U ONLY APPLICATION ACCEPTED BY - ---------- DATE- '; REVIEWEDBY------------------ ------ --------------------------------------- ----------------------------------------------------------- DATE-------- --- ---------------- ----••---------------------- BUILDINGPERMIT ISSUED----------------------------------------- ----------------------------------------------------------- DATE------------------------------------- -- - ----------------- Alterationsand/or recommendations:-------------- --- ----------------------------------------- ----------------------------------------------------------------------•--------------------------- --------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------- ------ ------------------------------------------------------ ----- --- ---------------------- R 1G' ---- -- --------------------- FINAL INSPECTION BY: _ . = '� -- ---- ---- -- ---- ---- Date_ ----- ---- -- - -- ---..`. SAN JOAQUIN LOCAL HEALTH DISTRICT 1801 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California v Manteca,California Tracy,California r.P.G O.