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w 7 � APPLICATION FOR NITATION PERMIT Permit No. (Complete in Duplicate) Date Issue Y 1 d ______ ____- _ VA, Applicaion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. T is application is made in compliance with County Ordinance No. 549. �JOB ADDRESS AND LOCTI -- --------- �- -------- -- - - __ _ _ ________________________________________________________________________________________ ' � PhoneQ ( - ---- Owner's Name--------- - - -� T ` ------------------------------------------------- ------- ------ ??,} - Address-----------'--- ---- -------= --- - ------ - ------------'---------- - ---------------- / ----------------•------------------------- r ------------ Phone Contractor's Name___ - - ------ P 'i Installation will serve: Residence IA Apartment`House ❑ Commercial ❑ Trailer Court ❑ Motel Other E3 i q } --AF ---- ---------------- 1 Number of living units: ----I-_ Number of be _n[--- Number of baths ____I__ Lot size _____. ra Water Supply: Pub4ic system X Community system ❑ Private ❑ Depth to Water Table. Character of soil to a depth of 3 feet: Sand ❑ j Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[7� Hardpan ❑ Previous Application Made: Yes El No Xf New Construction. Yes X No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----}-----------Distance from foundation--------------------Material--------------------__--------- •� ---------- J No. of compartments-------------- ------ .... --------Liquid de th__________________________Capacity .. •--�----------- - D"sspos Field: Distance from nearest well______ Distance from foundation_______________-_..Distance to nearest lot line_________________ Number of lines "'� - Length of each line-----------------------------Width of trench----------------------------------- - €;�, Type of filter materia!'..........) -------- Depth of filter material---------} .--------=Total length------------------------ ". .fes =' * A Seepage Pit: Dis#ante to nearestppwell____ 0'___-__:___Distance from foundation �7�{� Distance to nearest lot line_ - Number of pits--+-=f---------------Lining material---�p f_-----Size: DiameieV_-, 3 - ._Depth__p�.�`-- -- of fA--- Distance from nearest well-- material__________________------____________. ❑ Size: Diameter --------------------Depth---------------- _�"Ljrquid rCapacity----------------------------gals. arest well------------------------------------------------Distance from nearest building--------------------------------------- Privy: Distance from ne ' Distance to nearest lot line----------------------------------------------------- -------------------------------------- ----- -------------------- - - rO� emodelli g and/or repairing (describe)_____________ _ _, - Q `----- �` ------ --- — ----------- --------------------------------------- ------------------------------------------------ I ------------ -----------------...---•------------------------------------ -------------------------- ----------------------------------------------------------•- '> iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 7 0':nces, State laws, and rules and regulations of they San Joaquin Local Health District. Owner and/or Contractor) ----------------------- (Title)_ r Y•� __________ r flan, show` ize!f lot, location of system in rela tion to wells, buildings, etc., can be placed on revers side). A �" - '• FOR DEPARTMENT USE ONLY 1 APPLICATIONACCEPTED BY C' ----------------------------'----------------------------------------------------- DATE-� -------------------------------- - REVIEWED BY �------ ' )'A DATE--:7:7------------------------------------------•------- BUILDING PERMIT ISSUED___-______�Y__ --- ---------------------------------------------- DATE •--�_�---- --------------- ------------------------ Alterations and/or recommendations:----------------------------- -- ------ --- -------------------------------------------------------- c ---------------------------------------------- - _______________________________________________________ _ f _____________________________________________________ ___________________________ I ---1 SV jCFINAL INSPECTION. BY:--------- Date----- *// -- ( SAN JOAQUIN LOCAL LTH DISTRICT 130 South American Street 30o West Oak Street 132 Sycamore Street 814 North "C" Street N Stockton, California Lodi, California Manteca, California Tracy, California 1 �h :,4ES-9--2M Revised 1-57 F.P.CO. -- S