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1,. c ��1 = APPLICATION FOR _ 9ITATION PERMIT •/ Permit No. .....`{ (Complete in Duplicate) ed . ,� Date Issu -.7-.'' 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. 54.9. JOB ADDRESS AND LOCAT _____________ s____----._____ -- - ---------- Owner's Name------- = - ------------------------- ------------ - -------------------- Phone-•--•-.------------------ -- !� Address----------� �".'Q---- ---==--------------------•- -- ---------------------------------------------•----- -----------------------------------------•------.......`,,-�--_----------------------._._.. Contractor's Name _ ---------------------------------- Phone-- --- -.--•- -------------- ----- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:.'___I_--- Number of bedrooms __-f_--_ Number of baths __i._____ Lot size -� ��-�1_�__:?��'U__________________________ Water Supply: Public system•!'❑ Community system ❑ Private 2v —Depth to Water Table't�I ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel f] Sandy Loam ❑ Clay Loam ❑Clay ❑ Adobe[Hardpan p Previous Application Made: Yes ❑ No New Construction: Yes +[ No ❑ FHA/VA:'Yes 0,, No [ i TYPE OF INSTALLATION AND SPECIFICATIONS: I } (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) L Septic T nk: Distance from nearest wells ,Q�___.__-Distance from foundation____ ____________Material___ _�_._.__________....... ___ V No. of compartments---_-Z-----------------Size-___J�___ - � _—'_Liquid depth---- --" --,'--------Capacity___c�a t-•- . Disposal. Field: Distance from nearest well.__-5'_4 ---Distance from foundation____ Distance to ne$rest lot line_________ ______ Number of lines------__I-------------------------Length of each line-----_�5_-0-.`_------; �------.Width of trench..:._?-----------_-------------- Type of filter material_*��----------Depth of. filter m __- aterial_ J_z__________Total length________ __B______________________ Seepage Pit: Distance to nearest well-___!_O_ ----*--Distance from foundation_ -.___:Distance to nearest lot line______.____-._._ Number of pits------%---------------Lining material___�-4-il-_-__..'Size: Diameter----?_g ..__..____.Depth____3©__------- ------ Cesspool: Distance from nearest well--------____"___Distance from foundation_._.___''.....".- Lining material--____________:_____________________ [] Size: Dia-meter-----=-------'-----------x------------Depth------------------------------------------- --------Liquid`Capacity------------ -------gals. Privy: Distance,from nearest well---- ----------------------- g-------------------------------- --- ______________._Distance'from nearest building _._. ❑ Distance to nearest lot line-------------------------------------=------------------------------- ---------------------------------------------------------------- - Remodeling and repairing r(describe) l �`u v�` e " ----------------------------------•-------------------------------- ---------- ---•--------------- -----------•------------•----- ----------•-=-------------=------------------------------ --------------------------------------••-------------------=------------------------------------ -------------------.-----------------------------------------------------•---------------------------------------- --------------------------------------------------------•--------------------------------------- --------------------------------------------------------------------------------------- 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. --------------------------------------- Oer and/or Contractor) (Signed}- ------------- ------ ------------= - - ---------------------------- --- wn { � � {Title) -------------------------- (Plot plan, showing size of t, location sof system in relation to'wells,-buildings, etc., can be placed on revers side}. i L FOR DEPARTMENT USE ONLY Y---------------- ----- -------- ----------------------- ---------------------------------------- DATE------------------\ ----------------------------------- .:� .BY_ON ACCEPTED 8 - =------------ ------ DATE------------'- •---------•- BUILDINGPERMIT ISSUED-3 -------------------------------------------- DATE------------- ----/------------------------------------------- Alterations and/or recommendations: ------------------ ---- ' Dl A- --------------------------------------------------•----------�-------•-----------•------•------•-•---------- f I �/J CC f y"-------------------------------------- I f- -•--`-f-� --- ---- -- -------•----- ------------------------------- ------------------•-------------• -- ------------ •---•- --•---•-------------------------------------- ------------ --------------- - ----------•------------------ ---------- -------------------- -------------------- FINAL INSPECTION BY:-- �`"f / -------------- Date__ ----------------- ------------- ---- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California 1r Lodi, California Manteca, California Tracy, California H ES-9-2M • Revised 1-57 F.P.CO. +