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I l �V APPL.ICATION FOR=,,,NITATION PERMIT Permit No.-_�.,K d (Complete in Duplicate) OG Q Date Issued ------' ----- -7.__-_-- pplication is he m made�to the San�Joaquin Local Health District for a permit to construct and install the work herein described:— his application is made in compliance with County Ordinance No. 549. : JOB ADDRESS .AND L ATION_______-------- •' t Owner's Nam Q Phone. Address_ Il - ------ ---- ---- --- --- -------------- -- - -------------- - _ _ . ' m 4 Contractors Name------ -----:- ---------------------------------------------------------------------- ------------------------------------ Phon T Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court ❑ Motel "her ❑ Number of livingunits: _. Number of bedrooms Number of baths i ___ Lot size .........t_� ` - �-�� Water Supply: Public system '`Community system ❑ Private ❑ Depth to Water Table�e.�$"ft. Character of soil to a depths;of 3 feet:. Sand [❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E] Adobe Hardpan ❑ Previous Application Made: I Yes No E New Construction': Yes No E] FHA/VA: Yes E] No r` TYPE OF INSTALLATION IIAND SPECIFICATIONS: 1 (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) F t epttiiccTank-, Distance)€.from nearest well_________________Distance from foundation--------.-_.__------Material_____-_.__-_____._.__-______-____-_.__.______.. t yd No:.of compartments---------------------------Size---------=----------------------Liquid depth--------------------------Capacity----------------------- ,.Disposal.Feld: . Distance•ifrom nearest well...---------------Distance from foundation--------------------Distance to nearest lot line----.__...------- Type of 'filter lines_________ _ _________ _ __._Length of each line--_-_____ .__________ __.Width of.trench_, Number filter material-__ _.___ _----Depth of filter material------------------------Total length ________ Seepa,g Pit: Distance9to nearest wel�,;ii-tp-___ Distance from undation__._, ___-Distance to nearest,lot Number'o. f pits_--f- Lining materia- -----Size: Diame_ter___- ........Depth.' ___Distancei:from nearest well_______.__.__.__Distance from foundation------------__.-----Lining material--__--_•_____ _________�___=__ssPDo $'ze`'Diameter--------------------------------------Depth ------------------------------ Liquid Capacity------------------------- __ als'}. Privy: Distance from. ea'rest well______.-_--------_________________________ Dista ce from nearest building r, 1 ❑ g-•--------i--------------------------- W Distance to nearest lot line.------ ---------------------------------------- ------- Remod i an, ,or repairin��(describe) -- � -C -- �u � iI i i f - I e - •----------- ------------ ------------ -. =t -. =# -•----•--•--------------•------------•---------------•----•---- ------------------- y j •-•- - --- ----- - ----- - - --- -- --- ------------ - --- ----- ------ - - ------- -- - - -- - hereby ------- - ----- - - - I certify+ka+ I !i eve,prepared this;application -and that the work will be done in accordance with San Joaquin County, r ina ces, a law , an rules and r tions of the San Joaquin Local Health District. �,.'.. (Sig ) -----------,-----t ------=----------------------------------------------------------------------------- - --(Ownera rContractors $y=--="=--------- --- --- ----� ------ -- --•--- -- �� - ----_- .------------------- {Title - � (Plot plan, showing`size of lot, location f system in'relation to wells, buildings, etc., can be �a e��d on re arse ' e. P ,�} FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ----- ----- ------------ ---------------- ------ DATE------ - REVIEWED BY " ------ ------------------------- ---------•---------------------------------------- DATE--- ----- ------ = -----•------- BUILDING PERMIT ISSUED- _- DATE ---- -------------- Alterations and/ormreco e. dat'ons: --- ---- ----------------------------------------------------------------- -------•--•--•------•------- �` ------- -- ----- - - ----------------------- - - - -- -r -------- -------------- ---------- ------------ -------------------------------------- ---------------------------------------------------------------------------------------- ------------ FINAL INSPECTION BY:--I -------------------------------------- Date-------- _ _. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 1 300 West Oak Street 132 Sycainore Sfreef 814 North "C" Sfreef Stockton, California II Lodi, California Manteca, California Tracy, California i 1=S-9-2M Revises 1-57 F,P.CO.