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P FOR OFFICE USE: <br /> _____ ________________________.__..._..__ _____.___... APPLICATION FOR 5TigNltTfON PERMIT Permit No. .!__..! <br /> ..............................-................. (Complete-in Duplicate) <br /> -- This Permit Expires 1 Year From Date Issued Date Issued� _`_ - , <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549, <br /> 17 <br /> JOB ADDRESS AND <br /> Owner's Name-n--v�1 ------- ---• - Phone-9k_S,4Sq------•--- <br /> Address 0.V�b--- --- <br /> o ----••----------•----•-----••-------------•--------._..__..-... ..... <br /> Contractor's Name_.Ak_�-_c_ Phone......._-_----.---I.............. <br /> Installation will serve: Residence Apartment House [-❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: I----- Number of bedrooms Number of baths__�----- Lot size ..... ------------------------------ <br /> Water Supply: Public system ,ice Community system ❑ Private ❑ Depth to Water Table ------ - ft <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel'❑ Sandy Loam-❑ Clay Loam ❑ Clay ❑ Adobe , Hardpan ❑ <br /> #. <br /> Previous Application Made: (If yes,date------------------- ) No ❑ New Construction: Yes ❑ No ❑,, FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well---------._-____Distance from foundation------------_-------Material ------------------------------------ ----------- <br /> ❑ o No. of compartments-------------•---------. Size------------- -- -----------Liquid dj Rth--------- ------- ------- Capacity----------------------- <br /> Disposal Field: Distance from nearest wefi_. ]�-' ------Distance from foundation---��---..__.._.Distance to nearest lot line----ur-- <br /> Number of lines.'.._ .._ Width of trench--_._-c- <br /> - -�--- - ---- ------Length of each line--------- Q.--'-'-'�-'---' <br /> Type of filter material_K ---TK_.Depth of filter materia!___[- '__:_-__:_._.:_Total length_-..__ ._ - <br /> --------------- <br /> Seepage it: Distance to nearest well __--------____..___Distan(fe from foundation___________________ Distance to nearest lot line----------------- <br /> F-1 Number of pits--- ------------------Lining material---------------------- Size: Diameter-----------------------Dept h-----------------.------.-.---_.- <br /> Cesspool: Distance from nearest well ________________Distance from foundation_-_____-____-_ _ Lining material--------------------------------------- <br /> El <br /> _----- _---------:----_-.❑ Size: Diameter " Depth - ------ ------ ----------------------------------Liquid Capacity. ------------ -------------gals. <br /> Privy: Distance from nearest well.... ---------------------Distance from nearest building-------------------------------- -. <br /> ❑ Distance to nearest lot line-------- ------------------- ------------------------------------------------------ - ---' <br /> Remodelingand/or repairing Idescri e)=------- -------------------------------------------------------- ----•--•---------------------------------------------------------------------•--- <br /> ------------•-----••-------•-• -------------------- .. <br /> I <br /> - --------------------------- ------------------------- ---- ------------------- ------------ ---------------------------------------------------------------------------------------------------- ------------- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with'San Joaquin County <br /> ordinances,.State laws, and rut nd regu ' s of the San Joaquin Local Health District. <br /> � s <br /> (Signed)X------ ---- --- - --------- --------- -- _- ------- - ------ - ------------------------------- --------------- ---- - - --- -------(Owner and/or Contractor) <br /> By:-------------------=--------------------------------------- <br /> --------------------------------------- <br /> ------------------ <br /> (Title)--------......... . .._...... --'- ------------ <br /> (Plot plan, showing size;'of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> f FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY_ - - -,------------------ ------ DATE--.._ <br /> - -- ' <br /> REVIEWEDBY----------------------------------------- - - ---- ------- ----- --------------- ----------------=--------------------- --•--• DATE.__.. --------- <br /> BUILDINGPERMIT ISSUED---------- -­1-------------------------------- -----------•----------=------------------ ---------- DATE-------------------------------- ---------------------------- <br /> Alterati ns dor ecommen tions:. - .... ...-- o---- ------•- - - ----------------- ---- -------- ------------------- <br /> ---- -:__ - b _.�__ <br /> -'------- -- --- -------- ----- ---- - --- - ------- - - i�� - - - - -------- -------'-- <br /> : <br /> C y <br /> ----- - -- -.. .- ---- -' ' - - . .-' - -------- •----- - - -- - - -------------' <br /> FINAL INSPECTION BY:------------ -' -------- - --' - -------- ------._. Date-------- -----'- -'-'- - � --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1401 E.Hasetton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h'Street <br /> Stockton,California Lodi. California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vanguard press <br />