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FOROFFICE USE: l � r1rl.S-------- - ----------------- -------------------- --------- ----------------_________________ _____ ___________________ APPLICATION FOR SM1TA7ION PERMIT Permit No. ..d------------------- ------------------- --------- ---- --------------------- (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 wi ount Ordinance o. 4.9.••...x�-- , j JOB ADDRESS AND LOCATION D.-I .1.- 62,1!0 ` ll�-: Owner's Name &s''-------- —`---------'��. �L- Phone ?-- l Address -----itH�. . ---- •-------------- / �j Contractor's Name----------------------------------------------- fi/lvlr� �IV-C ------- Pho4-Uo-f-k-177----- Installation will serve: Residence01 Apartms ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---1--- Number of bedrooms _- umber of baths 1------ Lot size -40_0-A--.IfZ-1-- ----------_ Water Supply: Public system`)rg'6 Community system ❑ Private ❑ Depth to Water Table,70.- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe I& Hardpan ❑ Previous Application Made: (If yes,date-------------------_) No %- New Construction: Yes ❑ No$ 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-----------------Distance from foundation--------------------Material___.__---_..---..-..--_------__------_.---_---_- IfrC,5 t't^l� No. of compartments-------------------- - ---Size--------------------------------Liquid depth------------- ------------Capacity----------------------- Disposal Rel Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line.------------__- ❑ +� Number of lines-----------------------------------Length of each line-----------------------------Width of trench--------------------------------•_ - 0 ' Type of filter material-------------------------Depth of filter material-----------------------Total length-----------._---.----_-----_------------_. N Seepage Pit: Distance to nearest well/l.0-N4.7_-Distanc from undation--f47-.---._-_.Distance to nearest lot line---1p.^_.. Dumber of pitsOW-- 6-)-----Lining materia!- 3-3 Dept h.--.Size: Diameter.3-3- �_- __---De �� 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):_.__ ._ .- - .�_------------- - ---------------- -_ �+ -•- ----r ------------------------------------------------------yandg -----------------------------------------------------------------•---------------------------------------•-------- --------------------------- I hereby certify that I haveis application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rulestions o he San Joa in Local Health District. (Signed)----------------------------------------- -- ---- -- ----- --------------- -.(Owner and/or Contractor) BY ------------------------------------------ OV-3------ ---------------------------------{Title)----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be place'd on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----Ctl - - ------------------ -- - --- ---- ------ -- - ---- ------------------- DATE---`1-�----Z-d---- - ------------------------------ REVIEWEDBY------ ------------------------------------------------------------ -------------------- --- --------------------------------- DATE------ ------ -------------------- BUILDING PERMIT ISSUED------------- --------------------------- ------------–------ ATE ----- -------------------------------------- Alterations and/or and/or recommendations: _.'_-_�-11_- -� _.J(1 Of-I ------ - -- ---------------------------- --------------------------------------------------I----------------------_-_-_------.-..--.---------------------_---------_-----------------_-._._-_----------------------------------_-_--------------------.---------.__--_- FINAL INSPECTION BY------ ----- -- - ------- -. 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.C O. '�