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FOR OFFICE US ---- ----- ---- --------- ----------- ------------------ APPLICATION F % 'NITATION PERMIT Permit No. - sr (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 a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. / JOB ADDRESS AND LOCATION--------L - ---IS- -------------{--- � �� _. ✓ ----------- _ -------------------------------------------------------- r Owners Name---------------- -'--------, ) ,-2 —f---------------------- --=- - ------------ -- ._._. Phone_��•`� ��.t r I Address--------------------------f 2 ,_�----- Contractor's Name -_a r? ---------•-•---------------------------------- -------•---------- - ----------------------------- ------ Phone.......................----•------- Installa}ion will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A____ Number of bedrooms .-_51�_ 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 Ll,'Hardpan ❑ Previous Application Made: (If yes,date_t -47� No ❑ New Construction: Yes ❑ NoFHA/VA: Yes ❑ No ❑ V TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) O Septic .enc Distance from nearest well-----------------Distance from foundation--------------------Material __________________-____--__________- -____. No_ of compartments- _Size_ Liquid depth--------------------------Caacit Disposal Field: Distance from nearest well=.----------Distance from foundation__a `a`_.__ Distance to nearest lot line____ N-------- Number ----_Number of lines-----------J------____________Length of each line_______ __ ' Width of trench-. ----___------- T pe ______ Type of filter material- r _Depth of filter material____-j _____Total length_________ -' _._ _____________ Seepage V it: Distance to nearest well___`-----------------Distance from-f Lln on__/�f� __.Distance to nearest lot cine;Z3__ __._ 14 t ® Number of pits.....______________Lining mate"al. c'.__ 5iz : Diameter____-_-_. __._._.-____Depth___ .: ''��_l Cesspool: Distance from nearest well-.-.------ -__Dista oundation___________________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):---- •! �`�-' SEA--_----E-E'. - � ==t --------------------------------------- ----------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------•------------- ------- ------------------------------------------------------------ -------------•------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Ste to-laws, nd rules and regulations of the San Joaquin Local Health District, '"T 1 � (Signed)----1----- -=-- --_-"''�-----"-~==`-J------------------------------------------------- -- - -- ------------------- -------------(Owner and/or Contractor) C, 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---------------- = 0�__er7-------------------------------- DATE-------L -�::A- .'�----------------- REVIEWEDBY-------------------------•------------------------------------------------------ ------------------------------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------------------------------------------------- --------------------------------------------- DATE------------------------------ ------------------------------ Alterations and/or recommendations----------------------------------------------------------------------------------------------------------------------------------------------- --------------- ---------- --------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- ....-------------------------------------------------------------------------------------------------------------------------------------------------- - J j FINAL INSPECTION BY:---- ------------� _-_ Date--------------- JOAQUIN LOCAL HEALTH DISTRICT 1601.E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.00. 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