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-SFO FFICE USE: .�f2.�--------. ,. d�, Q APPLICATION FOR Sk..:....-.u TION PERMIT Permit No.'gi!'.�.n�..!?�..._.__ ------ ------ (Complete in Duplicate) --------------- This Permit Expires 1 Year From Date Issued 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 LOCATION J - - - --------4---- / . Owners Name -- --- am_- ` --=------------------- Phone----------------=------------------- .��- . .Address. 4 ------------ Contractor's Name---- cQ� ---- - Z --------------------------------------------------- - ----------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----I--- Number of bedrooms _2- Number of baths __1-..- Lot size ©_ --- _ ___________________ _------ Water _ __Water Supply: Public system ®Community system ❑ Private ❑ Depth to Water Table -4-0 ff. Character of soil to a depth of 3 feet: 'Sand ❑ Gravel ❑j Sa dy Loam [] Clay Loam ❑ Clay (] Adobe�ardpan L]Previous Application Made: (If yes,date--------------------) No New Construction; Yes ®'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 f,om--fou,idationll0---------------Material------ -________________________�_------./ No. of compartments--__=dZ-----------------Size------3__�(-4--�C-- ---Liquid depth....-----------------Capacity-----X-�� Disposal Field: Distance from nearest well._.'-._----Distance from foundation----/Q_....._._.Distance to nearest lot line----5...... ' [� Number of iines------I----------- ------Length of each line----jFG--- --------------Width of trench--- --,;f-_a ------------------ Type of filter material__�__j?&i_k--------Depth of filter material-----fir.T_._...----Total length--_____. O_'----------------------- r r i Seepage Pit; Distance to nearest well______________________Distance from foundation_ ____.-_-__-- Distance to nearest lot line__v.1J_________ dr Number of its___ p 1: -------------Lining material__.�i�©&_!"--.Size: Diameter----�,�._fDepth------ --.--_ Cesspool: Distance from nearest well-----------------Distance from foundation-_i---------------Lining material--.-..__---._--._-..-_-_.__-----____. ❑ Size: Diameter-------- ------------ Depth------------------------------ t-------------Liquid Capacity-- -------------------------gals. . Privy: Distance from nearest well------_-----___----------------------------------Distance k from nearest building------------_------.-____--_._...-_--_-. ❑ Distance to nearest lotline-------------------------------------------- ------------- ----------- t Remodeling and/or repairing (describe):--------------------------------- _ _ -__----------- ------------------ ---------------------•-------------------- ------------------- E 4 I -------------------- ------------------------•--------------------------------------------------------------------------------- --------------------------------------------------------- ---------------- i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin - Count ordinances, State laws, and rules a d reguiations of.t San Joaquin cal Health District. (Signed)---------------------------- - - ----- .... -----�------ - - -- -- - -- -------- ---- ----------------------- -------.(Owner and/or Contractor) i By:------------_-------------- --•---•--f-------" --- ------------(Title)----------:---------- - -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). x FOR'DEPARTMENT USE ONLY' APPLICATION ACCEPTED BY---------- -- ----------------------------------------------------------------- DATE-- REVIEWED BY-.--.--, --1 -- ------------- DATE------------BUILDING PERMIT ISSUED- -------------------- ------ ------- DATE------------------------------ ---- - ------- \ Altera_tions and/or recommendations: _ ._ — -.____.__i_____________ ______________ CQ Q ---___----___- _ _. ----------------- ------------ - -- - - -------------- -------- ------- FINAL INSPECTION BY:. - -------------- ---------------------------- Date---------------- ------------------------ SAN ---------- -SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stocktom'•Californid- .Lodi,California /Manteca,California Tracy,California F.P.QU. 4--