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FOR OFFICE USE: --------------------------------------------------- ----- APPLICATION FO LSA[_ITATJDN PERMIT Permit No. I-17......... . ------------------ ------- --------------- ------------- (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 C untyOrdinance No. 549. JOB ADDRESS AND LOCATION--j-'i _-- --------------- ----------------- ---------- --------- - n -------•----•--- --------••---- Owner's N L/-`-4�✓�(/�-. ------------ ------------ �1 ! Z! r Phone •-------------------- Address ---- ------ ------ -------------------------------•--------------------------- Contractor's Name LL � -------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___t____ Number of bedrooms -(3-- Number of baths --I---- Lot size _/A4._-Kis-Q._..__-___-_____.--_______.------ Water Supply: Public system ❑ Community system ❑ Private YT'_'D_epth to Water Table _49 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0�—_Hardpan ❑ Previous Application Made: (If yes,date---------------_____1 No [" New Construction: Yes ff"'No ❑ FHA/VA: Yes Ry— o ❑ 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-R�6-.-______Distance from foundation__.j0__--------- Material__`- 'z----------------------------------- No. of compartments------ -------- -------Size _x x-9-----Liquid depth__-_'9_Y--------------__Capacity--�'Q®` Disposal Field: Distance from nearest wen t?_____.-._Distance from foundation_1 foundation--14P---4---------- to nearest lot ��line__ i o rr N Number of lines---- --------------------------Length of each line---A�_c_{,Q-----------Width of trench----- ~=.-_ &______ Type of filter material'-o-e-jC--------Depth of filter material__Lr---------------Total lengfh_.X1r0---------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------.------Distance to nearest lot line_______-_________ ❑ Number of pits----------------------Lining material----- -----------------Size: Diameter------------------..... Depth------------------_--_---------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------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 {descr;be)---------------------------------------------------------------------------- ----------------------------------------------------------------------------- -------------------------------•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------- --------------------------------------------------------------------------------------•---------------------------------------•----•---------- ----------------- ------ 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 rulesand regul tions of the San Joaquin Local Health District. {Si ned �-; 9 )---------- -----{Owner and/or Contractor) 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---- '----=�-•- ��`-'1--.— -- ---- -------------------------------- DATE--------e� ---��--��--`-'r ---------- REVIEWEDBY-------------------------------- -----=---- - ----- ------------------------------------------------------------------- DATE------------------------ BUILDING PERMIT ISSUED------------------------------------- ------------------- ------------------ DATE Alterationsand/or recommendations:------------------------------------ ------- -----------------------------------•-------------------------------------------------------•------------------- ---------------------------------------------------•---------------------------- ------------ ----------------------------------------------------------------------------•------------------------------------•--•-------- -----------------------------------------------------• -------- ------------------------------------------------------------------------------------------------------- --------- ----------------------------- ------- ------------------------------------------------------- -------------- - ---- --- --- -_--_1-___---------------------------------------------------------------------- ----------------------- ------- ----------------- FINAL INSPECTION BY: -`�� Date...---- --- = SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street l - Stockton,California Lodi,California Manteca,California Teacy,California F.P.Go.