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VOL- <br /> - ------------------------------------------------------ APPLICATION FOV SXNfTATION PERMIT Permit No. <br /> --- ----------------------------------------------------- (Complete in Duplicate) <br /> -- ----------- ------------- -------- <br /> - ----------------- This Permit Exi Date Issued <br /> fires I Year From Date, Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein clescrUid. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOTION.-1—FA-Z-- ---------lle 0 <br /> Owner's C,�.�. <br /> ...........i------------------------------------------------------- .............. -- <br /> ----••---•-:•-•-------- <br /> Address........1.2.]A. Phone................. <br /> ..................................................................................................................................................... <br /> Contractor's Name___---- ____ <br /> ----------------------- ---------------------------------------------_--------------_----------_---------- Phone <br /> .Installation will serve: Residence Apartment House E] Commercial [I Trailer Court 0 Motel 0 Other <br /> ❑ <br /> Number of living units: A-_-Number of bedrooms _Z_-Number of baths J---- Lot size n�J�00 <br /> Water Supply: Public system Ui--Community system E] Private [] Depth to W.ater Table A41.-ft. .­­................................ <br /> Character of soil to a depth of 3 feet: Send El Gravel E] Sandy Loam E] Clay Loam E] Clay 0 Adobe[}.Hardpan [] <br /> Previous Application Made: (if yes,date"___________________) No El New Construction: Yes [] No-[3 FHA/VA-. Yes [-] No <br /> ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sp.ptic Tank: Distance from nearest well--------- <br /> No. of compartments----------- --------Distance from foundation.,------------------Material................................................ <br /> ---------------Size--------------------------------Liquid clep�h_-----------------------Capacity�........... <br /> D;spo Distance from nearest well_,*%arP%Z---.-Distance from foundation_..107-----_-----Distance Distance to nearest lot line.- <br /> Number of lines------------- -i C/ ............... <br /> Y01114 - ----------------Length of each line---------- -- ---------------Width of trench Z f, .1 <br /> Type of filter material... ------Depth of filter material-----/Jr-A' ...... ........... <br /> Seepage t: Distance to nearest well_,-Aa—.j-------Distancg-i[Qm founclation-/0-1 --------Total length------- . .......I............/...... <br /> IrNumber of its.- ._. ----------Distance to nearest lot line_.:�7......... <br /> -1-------------Lining rnaterial..__JAL#r,4-----Size: Diameter_0- .�-------------Depth-------AA:�------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material <br /> Size: Diameter---------------------------------------Depth-------------- ----------------------------- <br /> -------- <br /> -------------------------------------Liquid Capacityy------•---- gals. <br /> Privy: Distance from nearest well------------------------------------ ------------Distance from nearest building--------_-------------_----------- <br /> ❑ Distance to nearest lot line------ ------ <br /> ------------------------------------------------------—------------------------------------- ------------------------------ <br /> Remodeling and/or repairing (clescribe):_-A___" I i <br /> -- -- ---------------------------------------------------------­----------­----------1----------------------------------I..................... <br /> .............................................................­­--------------------------------------------------------------------------------------------------------------- ---------------------------------------- <br /> ---------­------­------------I--------I......................I-----I----------------------------------------­­------------------------­--------------------------------------------------­--------­----------------------------•-----.•------••--------------------------------------------------------------------------------------------------------•-------------•--.-•-----...---------- ----------------------------------- <br /> I hereby certify that I have p airedt�s application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules dreg 1'on <br /> 5 of the San Joaquin Local Health District. <br /> (Signed)--------------------- ------ <br /> --------- ......... -- - ------- ---------- ---------------------------------------------------------------------___(Owner and/or Contractor) <br /> By:...----------_----- _.. _ .....--••- .­ ------------------ ---------------------------------------------------------(rifle)--------------------------------------------- <br /> (Plot plan, showing size of I loc ion Of,- "stem in lation to wells, buildings, etc., can be placed an reverse side). <br /> FOR kRTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-----C— <br /> _,7 <br /> V ---- - ------ -----------------------------------•--------------•--.------------ DATE- <br /> REVIEWED BY--------------------------------------------------------------------------------------------------------------------------... DATE--- ----- <br /> BUILDING PERMIT ISSUED................... ------------ ................................------------ <br /> ------------------------------------------------------------------------------- <br /> DATE. ------------------------------------- --------------------- <br /> AlterationS and/or reFoTmDndafions:----- -------------------------- --- ---- ------- <br /> ----------*- -- ------------------^---------------------------------------------- <br /> % <br /> ---------------------- ----------------------------------------- <br /> ---------------------------------------------------------------------4--------------------------------------------------------------------------- ------------­---------------------------------------- <br /> .............-------------------------------------------------------------------------- -------------------------- ------------------------------------------------------------------------------- --­---------- ------------ <br /> ................. -------­---------­_-------------------------------------- -------------------------- ----------------------------- -------------------------------------------I---------------------------------- <br /> --------------------------- <br /> FINAL INSPECTION BY:--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 124 Sycamore Street <br /> Stockton,California 205 West 9th Street <br /> Lodi,California Manteca,California Tracy,California <br /> EA 9 REV'SED 6-59 2M 5.61 ATLAS <br />