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FOR OFFICE USE: �6�--------------- --------------- -------------------------------------------------------- APPLICATION FOR7'S-A l)TATION PERMIT Permit No. . ..... ------------ - -------------------------------------- -- (Complete in Duplicate) � 3� This Permit Expires 1 Year From Date Issued 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 with County Ordinance No. 549. 'Z I JOB ADDRESS AND LOCATION-----;W/-- --------- - -- ------- Owner's Name----- -___ -_ ..... .. . - PhoneAj-"A.jK e- .. Address-------- ----•- ------ Contractor's Name---- ----- ------- -------- -- - - ---- -- -------------------- ----------------—----------•-------------- •-• --• ------ Phone----------------------------------- Installation will serve: Residence Efl Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: d----- Number of bedrooms_?-.... Number of baths 'I—Lot size ----- _ ________________ Water SuPPIY� Publics stem ❑ CommunitY system Private X Depth to Water Table/pYft. V3 �1 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 �j New Construction: Yes 5 -No ❑ FHA/VA: Yes ❑ NcK TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wbli -------Distance from foun ation--1._.d----------Material___ -------------------------- No. of compartments-----------2-----------Size__.��x_7� __Liquid depth--.. ZO'-------------Capacity------ Disposal Field: Distance from nearest well.,,6V----...-Distance from foundation,/4------------Distance to near st lot line- ------------ 71 � �/o, Number of lines--------- _ . ._.._-_ Len th of each line--_-- __l� ---.Width of trent -- ---------------- - ---.--_--.- Or Type of filter material.-____Depth of filter material----.1 _______..Total length___.__ !f_____.__._________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_____--____-_._.- ❑ Number of pits______________________Lining material-___-_ ---_------------Size: Diameter-------------- --------Depth ._---_______--_ Cesspool: Distance from nearest wall-----------------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):------ -------- - -- --- ------- ---------------------------------------------------------------------------------- ------------------------------------ ------------ ----------------------- ---------- --------------------- ----•--------------------------------------------------------------•-----------------.----------------------------------------------------------------- ----------------------------------- -----------------------------------------------------•---------------------------------------------------------------------------------------------------------- ------------------ ----- 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. �. Si ned fOwner and/ttorl BY=----------------------- -----------------------------------------------------------------------------------------------------------(Title).----------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- --------------------------------------- DATE------- 1 ------ ----------------- REVIEWED ----------------- REVIEWED BY--------------------------------------------- ------- ----._ DATE._-. ---- --------------------------- -- ----------------------- ------- --------------- ----------------------------------- BUILDING PERMIT ISSUED----------------------------- - - - 1�4 --------_-__-- -- --- D-- ATE__. ` ------------------------ - ------------ ---------- - Alterations and/or recommendations:_____...__ _y_s . ___.._ ______________ ----------j ------�� N--- - - - ------ ----------------------------------------------------- - - ---------- -------------------------------------------------------------- ------t ---------- - -- - ----------- ---- -------------------- ------------------------------ -------- ------- ---- ------ -- - - - ----------- ----- ----- --- e 6111", FI INSPECTION BY:---- lY' Z2 ------ ------- — &W-------------------------------- p w ----------------- pv rin� SAN JOAQUIN LOCAL HEALTH DISTRICT J d 1601 E.tlaxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.C4.