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HA. APPLICATION FOR,WA ITATION PERMIT Permit No. (Complete in Duplicate) v Date Issued _--.______ ,�{� Application is hereby made to the,San rJoaquin Local Health District for a permit to construct and install the work herein described. pp p y No. 544. � t 4t�l This application is made in com liars e with Count Ordinance JOB ADDRESS NQ LOCATIC`�i N___._ Owners Name_ - -- r �' ,_ ?'4..4 Phone 1t� V Address-...I s ---- - ----- Contractor's Norrie _ ' --1 ld+t ' d` ` 'S!= =. /L hone Installation will serve: Residence App artmeennt House ❑ Commercial 7 Wailer Court ❑ Motel r❑ Other ❑ k I Numbe�Ao living units: _ ---- Number of bedrooms - -- Number of baths --- Lot size ____ -p- - --r----- --- Water Supply: Public system ❑ Community system ❑ Private`.MDepth to\1/ater Table -------- ft. y Character of soil to a depth of 3 fe±t: Sand �. Gravel ❑ - Sandy Loam ❑' Clay Loam -] Clay E] Adobe Hardpan ❑ Previous Application Made: Yes ❑ No r� "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.)' a I Septic - nk: Distance from nearest well __________Distance frojn foundation _.-' *_.-__.Mat, - No. of compa-tments-_-�. ' `;_, ='Size_ = _ & '_:_ Liquid depth---------- CapaatY _- 6 . y li Disposa/f=ield: Mistance from nearest well )Distance from foundatio .Distance to nearest lot I'snH_ Number of Lnes___________ _ _ of each lin __.:___. 0f Width of trench______Z_�.-------.-------- ��_ --,.rte Length ' } Type of filter _+ 'D'et _filter,material____._�_l} -.__-___Total length___.._ �_, _____________________ + r" Seepage Pit: Distance to nearest well--------------_______Distance from foundation--_____..__._______.Distance to nearest lot line____-_-_____.___ ❑ Number of p!�fis----------------------Lining material-----------------------Size: Diameter----•-•-------- ------.Depth-__ ------------------------- ng--material ------------------------r Cesspool: Distance from nearest well________-_-Distance from foundation--------------------Liningfmaterial__.,_-__ ---______-.________-_._____. ------------------ Size: Diameter--------------------------------------Depth---------------- _-Liquid Capacity------ -gals. ❑ 3 Privy: Distance from nearest well_-_`�--------- --------------------------------Distance from nearest building-------•----A--------------- -,---- \ ❑ Distance to nearest lot line- -------------------- ----------------- ------------------------•----------------------- --------------- ----�----- ---------------------- ' r -V RemodeliT(g and./or'repairing(dasc�iLl-e):-----------------------------------------------------------------------------------------------------------_------------ ------- til _ = P X ---------------------------• ----------------------------------------------------------- _--------------------------------- ---------------------------- - --- - -----------------------------------------------------•------------------------------- ------------------------------•--------------------------------- I hereby certify that l have prepared 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. r �,Q (Signed)- - "'- ------------------------------------------------ --------------------- (Owner and/or Contractor) -- --- -- -- --�E-� l 13 :--•-- '��"" Tit e Y i-- ------------------------------- --------------- - - ( )- =-------- ---------•----------------------- ------------------ (Plot plan, showing size of lot, loc�a n of system in relation to waifs, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__--- ---------------- ---------------------------- ---------------------------------------- DATE 3 --- --------------------------- ------------------------------------------------------------------------------------------ ----------------------- - REVIEWED BY -----------•--------- ! --------------------------------------- DATE , ------------------------------ - ------ BUILDING PERMIT 1SSUED--•------------------------------------------ DATE._ Alterations and/or recommendations:--------•------------------ -- -------------------------------------------•-•-------••- ---------•-••-•---•---------•-- ---------- ------------------------------' ------------ r - ---------- - - i FINAL INSPECTION BY:.___�---------------= - ----------- � Date_--�---- - -- -- SAN JOAQUIN LOCAL HEALTH DISTRICT �. 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ` ES-4-2M Revised 1-57 F.P.CO.