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� PERMIT � F �--� Permit No. ----_---,,// APPLICATION FOR _-NITATION 7-.��5 (Complete in Duplicate) Date Issued '*Application is hereby made to the San Joaquin Local`Health District for permil• to construct and install the work herein described. This application is made in compliance 1'with County Ordinance No. 549. ',-JO. : Pho B ADDRESS A D LOCATION------- ------ ------------------- - ----------- ---------------�--------------------------- Owner's -Owner s Name------ ------------------ L ------ --------• - -- ---------- . - Name } ---- -... j (iAddress --------------------------------------------•----------------------.-.--...Phone- ------ ontractors --__ -1 s y ^d Installation will serve; Residence - Apartment House ❑ Commercial F] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _- "- Number of bedrooms _ Number of baths __7►- Lot size --- Q- - . i Water Supply: Public system Immunity system ❑ Private ❑ Depth to Water Table _--..-"ffl—i- Character of soil to a depth of 3 feet: .Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑*'%No [R-'_-New Construction: Yes 52-�No ❑ PHA/VA: Yes ❑ No 0� TYPE OF INSTALLATION AND,5PECIFICATIONS: _ (No septic tank or`cesspool permitted if public sewer is available within 200.feet.) r Septic Tank: Distance from nearest well------------- -Distance from foundation-------------------Material---------.-----------------------------�� ► ..---_-- -------Size- - `de th--------------------------Capacity---------------------- N No. of compartments---------------- = ----------------- Liuid Disposal FiDistance from.nearest well___.-.'___.._._Distance from foundation--------- ------.Dis#ante to nearest lot line___-"----._. - � Number of linesr ------------------------------- Type ------- ---------`-Length of each line------------------------------Width of trench----------------------.------------ Type of filter maferiaJ------------ -- ------Depth of fikter material------------- -------Total length--------------;-------:-------=----------- t-- �"�' i�itnce to nearest lot line--_--.-----"---._ Seep^a� Pit: Distance to nearest well _ A�-- _ _-__Distance from foundation_-1_i2.---------- Depth ---------------- Number of pitsi _-----.Lining material 44--0) - ---.size: Diamete�--- -------------------- -- Cesspool: Distance from nearest well- Distance from foundation--#_-----" --+-__.fining material--.---_-.-"_-- als. *!r r Liquid Capacity_ gals- ----------- - ❑ Size: Diameter------` :=; Depth `� - - i--- -------- ,q p ty----------------------" - s n. INA,��"rivy: Distan e from nearest well ------------- -- -----------------------------Distance from nearest building--------------------------------------- -to nearest lot line----------- -------------------------- -=------------------- ------- ------------ --------------I--------------------- *.� `---- _j 11 - _ Rema%delin and/or repairing (describe):--"_"" -_"_-"- �' --"--"•- �� ------------------------------------------------- ------------ ---•---------------•------- ---- --- - ---- - --- - - ---- = hereby certify that I have prepared this application and that the work will be done iri'accordance with San Joaquin County ordinance to laws, and rules and regulations of the San Joaquin Local Health District. Iland/or (Signed) {Owner an /o Contractor _ ------------ By_-------- - ----�-� �-------------------------------- etc: can(b!ele�faced on reverse�ide. (Plotplan, showing size o ot, location of system in relation to wells, buildings,- , p ) ` p FOR DEPARTMENT USE ONLY �y DATE------- APPLICATION ACCEPTED BY------------------------------------------'----------------------- ------ _ REVIEWEDBY--------------------------------------------- -------------------------=------------------------------------------------------ DATE---------------------------------------------------------- BUILDING PERMIT ISSUED.------- ----- -- DATE ` --------------------------------------- Alt ati ns and/or r@Fo mendatio :-- ---------�-- - -� Y------- ------ - - -------- -------------------------------- -------------------- ------- ------------------------------------------------------------ -------------------------------------------- ------------------------- Date ----------------------- F1NAL - _ ` ------------------------------------ - INSPECTION BY:.--------- ---------- Date �r �'�� ;:. SAN JOAQUIN LOCAL HEALTH 4DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet .814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M Revised 1.57 F P.CO.