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FOR OFFICE USE: ' APPLICATION FO`1-'S- NI�;ATION PERMIT ? Permit No. _rte _ s 0 ----------------------------------------------- ------ (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 permit to construct and install th work herein described. This application is made in compliant with oun dina�ce N . 549. �� Yc n JOB ADDRESS AND LOCATION____ Owner's Name --------------- Phone -------- - --------- Address------ L• "-•----•------------------•-•--------------------------._._...--. ------------ Contractor's Name----------------------- -------------------------- - ----- ------ Phone--------------------.-------------- Installation will serve: Residence a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A____ Number of bedrooms -------- Number of baths ________ Lot size ______________ ___ _ + Water Supply: Public system ❑ Community system ❑ PrivatejE4 Depth to Water Table �`__'_V_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ 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...... __L]_-_-_Distance from foundation_____ ____ _ Material----v.."--'-�W-1 It____________._..____- E p - ` � k�g k ---Liquid depth___'4-------- ---- --- Capacity--I i-(M------- No, of compartments.... ____________Size___._______ __________ Disposal Field: Distance from nearest well..!.'.�'�__'...._Distance from foundation Distance to nearest lot line__-__._... ® Number of lines-----�_________________________Length of each line------- ------Width of Type of filter material-,9_-----_----------Depth of filter material_.I_5_.................Total lengthj_S'A__________-____________._____- \W� Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------__---_. V) ❑ Number of pits----------------------Lining material------------------------Size. Diameter-----------------------Depth-------------------------------- Cesspool: ----- ------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---------------------------------------------------------------------------------------------------------------------------- -- 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, and rules and regulations of the San Joaquin Local Health District. (Signed)----- BY = _. ------ --------------------------------------------- ( _ ` - ." avd or-ContractorI _. — - ---- - ------------------------------(Title)----------------------------------------.._.....__._------- - (Plot plan, showing size of lot c� n of system in relati,tto wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- .. f --- ---- --------------------------------------- DATE-----�-- - ---------------- ----------------- REVIEWEDBY------------------------------------------- - ----- -------------- ------------------ ---- ------------------------- --------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------- ----- -- DATE.-- Alterations and/or recommendations•.______.. ,.� _______� _ _________ ------------------------------------------------- ------------- --�--^^'�------------------------ 1 r ...__•----------------------------------------------- •--------------"_.._..__...-----------------------'_..--------------------------------------- ----------•------------------- ............------------------------------------------------------__--.....................-------------------------------------.--------------------------------------------------------------------.------------------------ l FINAL INSPECTION BY-/A -------- ----._l``"�{a r Date---------------- - - --------------- ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.Ca. 3 -30 3