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. LI FOR SA 1 TION PERMIT Permit No,3�- - mpl i Icate) p Date Issued ---- --- -•-- - Application is hereby made to the San Joaquin Local Health istrict for a permit to construct and install the work herein described. This application is made in compliance/with Countyrdinance No. 54909 . ` JOB ADDRESS AND TION._ -------------------------------------------- � Owner's Name------------- O ! ------------------------==------ ---------------- Phone-------- Address-.-.------------ --------- Contractor's Name------- ---------------- Phone----------------------------------- `4 Installation will serve: Residence Apartment-House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J--- Number of bedrooms _ _. Number of baths _ ----- Lot size --------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [�' Iardpan ❑ Previous Application Made: Yes ❑ No [�r•New Construction: Yes 2--No ❑ Qx TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted..if .... publicfse r is available within 200 feet..), '' Septic Tank: Distance from nearest well..... . Distance from foundation...._l_�1..__.____.Material-___- ------Y`W-W, ---- ....... No. of compartments------------ ---; :Size---- x ------Liquid depth-------- — Capacity -. ` ' "f om Barest well.._,-- --.Distance froom foundati3n....___ ...-Distaste to.fnearest�lot"lin Qisp al Fief.. L�istance.,ff f u er ofiines.f - '`�� rLength�p#teach-line- 1Widtlt`�treft �, Type of filter matersal_�._�.-�s.-..__.1 __f_-.Depth of filter material...'.__,------�---Total length_ ..__._____..�-...__..__r / � d`�' -Distance from foundation__-_.--�0___,Distance to nearest [of line__.:._.__.___.. Seepage Pit: Distance to nearest well..-. _. � � 2�,.- p �„' ❑ Number of pits--------- ----------Lining material---------....__--- Size: Diameter-------..__-_---- ---.De th-----_-_----___.. .____...•.__-- 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 _.-...___ -----. ❑ Distance to nearest lot line------------------------ ---------------------------------------------------------- ------•-------------------- Remodeling and/or repairing(describe):------------------- ----------------------------------------------•----------------------.----------------- ---------------------------------•-----------------„--------•---------...�:----- *�� )------ __fn ._..-------------------------------------------•-------------------------- ---- -- - ----- --------------------------------------------------------------------------------- ---------- -- --- I hereby certify that I have prepared this applicafion and that the work will be done in accordance with San Joaquin County ordinances, S t laws, and rules and-ri,gulations of the San Joaquin Local Health District. {Signed}- '��- ------------------------------------ ----------------------------(Owner and/or Contractor) d -- ---- --»-. ------------- ---- �i�u�^-- -- - By:-------------- 11 - 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 APPLICATIONACCEPTED BY------------------- --------------- --------- - -�-- -------------------------------------- DATE------------ --- REVIEWED BY----------------------------------------------- - v' ------------------------------------------ DATE BUILDINGPERMIT ISSUED------------------------------------------•----------------T----------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations------------------------- ---------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- 11�- ------ -1-V-/ :: -------�' ., �. ''� -- ------------------------- __----------------------------------------- _.____-... ._.----_-_. -.__-..-.-__....._,__.-------------- _ __-._.---.----....____._____......_..----_-.___.......__..... --------------- ,�, . .��mv------r1c 'c Date-------- FINAL INSPECTION BY:....-- �� e/� ------------------------------------- -SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21A 8-51 Revised W-2100 ® +