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APPLICATION FO r4*'§ANk_1fATION PERMIT Permit No. <br /> ----------- ---------- --------------/---- - <br /> .It / _� -----------------------------!;�. -j-­ (Complete in Duplicate) <br /> --- ----- ---------- ------------------------------------ .This Permit Expires I Year From Date Issued Date Issued <br /> Application is hereby made to the San'Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ording7ce No. 549. <br /> JOB ADDRESS AND LOCATION__- cS <br /> - ----- <br /> Owner's Name_ .4 --------------------------I-------------------- <br /> -------------------C Phone <br /> Address <br /> Contractor's --­--------------------------I------------------------------------------------ <br /> ---------------------------------------------------------------- Phone <br /> Installation will serve: Residence [�parfmenf House E] Commercial El Trailer Court ❑ Motel 0 Other <br /> ❑ <br /> Number of living units. __j---- Number of bedrooms -3--- Number of baths _/.... Lot size <br /> Water Supply: Public system E] Community system El Private E!rl5epfh to Wafer Tabie.6,-q ft. <br /> Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam E] Clay E] Adobe En-1:Tardpan <br /> ❑ <br /> Previous Application Made: (If yes,date----------------- <br /> ___) No New Construction: Yes 9o El FHA/VA: Yes 0 No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_t3_0_`. <br /> I ---Distance from foundation-4L-------------M a fe r i a i-_12121-m4cle-ev.- <br /> No. of compartments------- -----------.__Size---,3--Xj-- _/---------------- <br /> Y_�-------Liquid clep�h_____j----------------_Ca acit o 0. <br /> D:sposai Field: Distance from nearest well.-_"R_`----Distance from foundat[on__A0 "*.._ --------Distance to nearest lot,line--- <br /> Number of lines--------L-------------------------Length of each line---�'.0_'_---------------Width-- of french- -.Zo- 0 <br /> Type of filter material__�7/?Ai`CA--------Depth of filter material-lk------------ _._Total length------1-0-- ------------------- ------- <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to <br /> El Number of pits------------- ........Uriing material----- ----------------.Size:'Diameter---- <br /> -- ----Depth----- -------------------- <br /> Cesspool: Distance from nearest well_______-1_______Distance.from foundation----- -----------...Lining material_______________-_---______-,_ <br /> Size: Diameter---- ----------- -------------------Depth---------------------------------------- -------------Liquid Capacity----------------------------gals, <br /> Privy: 'Distance from nearest well-________________._____-_ <br /> ___________ --------Distance from nearest building---------- ----------------------------- <br /> El Distance to nearest lot fine--------------- <br /> ----- --------------------- <br /> Remodeling and/or repairing (describe):____-..._____---_- <br /> ---------------- ----------------------------------------------------------------------------------------------------------------------- ---- - <br /> --------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------- <br /> -----------------_------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------- -------------------- <br /> --------------------------- -------------------------------------------------------------------------------------------------------------- ------------------------------------------ -------------------------------- <br /> I here6y certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rule�aregulafions of the San Joaquin Local Health District. <br /> 0 1 1 <br /> tc, <br /> (Signed)------------/----------C <br /> ................ . ------------- -----------•------- -------------------------------------------- ---------------------------(Owner arid/or Contractor) <br /> BY=---------------------------------------------- --------------------------------------------r-----------------------------------------(Title)------------------ -------------------- ---- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ---- - <br /> BY-- ------------(.'<-------------- - --------------------------------------------------------------- DATE-------- <br /> --- <br /> REVIEWED BY----------------------------------------- ----------------------- --------------- --- -------- DATE----------------- ----- ------------ ------------------ <br /> BUILDINGPERMIT ISSUED----- ------------------------------------------------------------------------------------------------ DATE----------- ---------------------------------- ' <br /> ---- ------------------- ------------------ <br /> Alferati6ns and/or recommendations:-____..__._ <br /> --------------------------------- --- --------------------------------------�?-------------------- <br /> -- ------------------- <br /> ......... ....-.• <br /> �- ------ O&C---- ------------ <br /> ---------- <br /> --------------------------- ----------- --- ---- --------------------------------------------------------------------- ----------- ------------------- <br /> FINAL INSPECTION BY:...... ... Date--------- <br /> -------------- --------- -------------- ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hatellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br />