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FOR OFFICE USE: j <br /> --------------- jPermit No. .e�/�5.. '�' <br /> APPLICATION FOR SA�NITAVON PERMIT <br /> (Complete in Duplicate) , <br /> This Permit Expires 1 Year From Date Issued Date Issued S--"/ <br /> . __._.- <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 /> JOBADDRESS AND LOCATION ;Z------ ------------ ----------t`�------�---------- - ------------------------------------------------------------------------- -------------- <br /> Owner's Name----- ----- S:g.f..---Q-v- -- ----------- Phone <br /> Address.-.--------- --t--Ly-g---•-------I.; -----------------------•-----------------•----------•-•----------------------------------------------------------------- <br /> -----------. <br /> ,��J ----- Phone.._. <br /> Contractor s Name----t .4�F y-t��-1 '.. - ...... <br /> Installation will serve: Residence OrApartment House ❑ Commercial ❑ Trai4er Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ..----- Number of bedrooms -.?— Number of baths .---I.. Lot size ..--___-------------------------------------------------- <br /> Water Supply: Public system W Community system ❑ Private ❑ Depth to Water Table-U�_ ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe;5,'Hardpan ❑ <br /> Previous Application Made: (If yes,date--------------------) No 2�r 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 /> Z,,> sr �fi'x 4,-- <br /> Septic Tank: Distance from nearest well-----r!�__Distance from foundation-------IA------Maaterial.lyy�C��S�.___ <br /> [� No. of compartments-._.__...�---------Size------�._--Liquid depth--- ------------------- <br /> Capacity...t'Ir. ` -- <br /> Disposal Field: Distance from nearest well.................Distance from foundation------ -------Distance to nearest lot I�e---------._.... <br /> Number of lines.............- 1�1------------Length of each line..___ Width of trench-------.A------------------------ <br /> Type of filter material..__ ,t3 _ __--..Depth of filter material.... .............Total length...----- ----------------- <br /> Seepage Pit: Distance to nearest well......................Distance from foundation.-- ----------------Distance to nearest lot line---------..___._ <br /> ❑ Number of pits----------------------Lining material--------.--------------Size: Diameter-----------------------Depth--.------._____---------.-------- <br /> Cesspool: Distance from nearest well----------------- from foundation....................Lining material-----------------------------------... <br /> ❑ Size: Diameter---------------------- ---------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. (� <br /> Privy: Distance from nearest well---------.---------------------------------------Distance from nearest bui{ding-------------.--------.-._-----------_.._. <br /> ❑ Distance to nearest lot lire- ------ --------------------- -- - ---------------------------------------------------------- ---------------------------------------- <br /> Remodelingand/or repairing (describe}- ----------------- -- -----------------------------•-------------------------------------------•----------------------------------------------•-------- f <br /> --------------------------------------------------------------•----------------------------------------------------------•---------------------------------------------------------------------------------------------------- <br /> ---------------------------- -------------------------------------------------•--------------------------------------------------------------------------------------------------------------.----------------­­---------­.- <br /> ------- ----------------------------- ---------------------------------------------------------•-------------------------------------------------------------I----------------------------------------------- - ------------- <br /> 1 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 rules and regulations of the San Joaquin Local Health District. <br /> (Signed) tea` C.,V4 = (Owner and/or Contraetarl <br /> g ---(Title)------C -�s 5� .... .... ....... <br /> y..-.- r...... . .. <br /> (Plot plan, showing size of lot, location of's� m in relation to wells, buildings, etc., can be placed on reverse side). <br /> F P RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY---------------- - - -- --------------------------------------------- DATE----A-� <br /> REVIEWED BY- ----------------------------- --- ------- - ----- --- -- ---- -------- ------------------------------- ------------- DATE------------------------ <br /> U <br /> PERMITISSUED-------------------- -------------------------------------------------------------------------------- DATE------------ <br /> Alterationsand/or recommendations:---------- ------------------------------ ---------------------- --------------------------------------------••-•------------------------------------- <br /> - ----- ------------------------------ ---------------------------------- --------------------------- -------------------------------------------------------- ----------------------------------------------------------- <br /> --------------------- <br /> -------------------------------------------------------------------------------------------------- -------- ----------------------------------------------------• --------------------------------------------------------------------------------- <br /> ---------------------------------- - ------- --- <br /> FINAL INSPECTION BY:..------- Date--.----- � Lam------------ -- ------------------ <br /> eS/NJO QUIN LOCAL HEALTH DISTRICT <br /> Q <br /> 1601 E.Hweellon Ave. 300 West Oak Street 124 sycamore Street 205 West 91h Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br />