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14 <br /> o <br /> APPLICATION FOR S Permit NaANITAT6�6_ERMIT P ---- <br /> (Complete in Duplicatel <br /> Date Issued _7-.-25./ <br /> A <br /> �plica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This <br /> application is made in compliance with County Ordinance No. 5g9. <br /> 7 <br /> JOB ADDRESS AND LO ATION--- ...... ------ 1� <br /> ------------------------------------------------------------------- ------------------------------------------------- <br /> Owner's Name________ ---------- ---------------------------- ---------------- ------------- ------------- Phone--- ---------- <br /> Address------------ ---------- <br /> -/------ <br /> ----------------------------------­------------------ ----------- •---- ---------------------------•-----•--- -------------- <br /> Contractor's <br /> ---------­.­--­-------------- <br /> Contractor's Name------- ------------------------------------------------------------------------------------------------_----------------- Phone------------------ <br /> ----------- <br /> Installation will serve: Residence 2---A"partment House ❑ Commercial [-] Trailer Court.E] Motel E] Other E] <br /> _ <br /> Number of living units: 1..__ umber of bedrooms ---2_---Number of baths /----- Lot size --- ----------------- <br /> Water Supply: Public system Community system E] Private E] Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 feet: Sand Gravel [] Sandy Loam [] Clay Loam 0 Clay F] Adobe 2;_-Hardpan [0]Previous <br /> Previous Application Made: Yes E] No ;��New Construction: Yes JVNo 171 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 fe <br /> fi <br /> Septic pek: Distance from nearest --------------------------------------------- <br /> ept' T arest well*o'�---Distance from foundation- ------Ma7tT r�pi__T <br /> No. of compartments-_02..................size�- ----Liquid depth------- -----------------Capacity---- <br /> Disp;�ell Distance from nearest' weli_/_V Distance from foundation Distance to nearest lot line.--'.5— <br /> "9 - --------- <br /> Number of lines---- Width of trench-----2-- ------ <br /> ....... ------:Length of each 71 <br /> ------------ <br /> Type of filter material--/` .......Depth of filter mater�al... -----Total length---- <br /> ---------------------------- <br /> -------------- <br /> Seepage Pit; Distance to nearest wel'I- ----------- --------Distance from foundation---------------------Disi-ance to nearest lot line <br /> El Number of pits--- ----------------Lining material-----------------------Size: Diameter--------------------- Depth----- ------ <br /> Cesspool: <br /> epth--------------- ------ <br /> Cesspool: Distance from nearest well-----------------Distance from founclati,5n___.------------- Lining.- material__.-----___ _---.-.---------------- <br /> ❑ Size. Diameter_---------------------------------- Depth-----------I-------- Capacity----------------------------gals.'Ir <br /> I ----------- ----------- --:!-:----Liquid <br /> Privy: Disfance from nearest well-------------------------------------------------Distance from' 'earest building---------------------------------------❑ - <br /> Distance to nearest lot line.__--------------------- ------------------------------------ <br /> ri <br /> ----------------------------------- ------------------ -------- <br /> Remodeling and/or repairing (describe):--------- -------- ------------------------------------------ <br /> ----------------------------------I-------------------------------------------------------- <br /> ------------------.........­-----------------------------------------------------------------------------------------------------*---------------------------------------------------------------11------------------------ <br /> --------------------------------------------------- ------------------------------------------------­­--------------------------------------­----------­-------------_1---------------------------------------- <br /> ------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- <br /> I hereby certify that I have prepared this application and fhaf the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the,San Joaquifi Loca-Health District. <br /> -------- -------- ------ ----------------------------------------------- ----jOwner and/or Contractor)-- <br /> (Signed)_---��­ �/j <br /> By------------------------------- -------------------------------------"-----------------------------------(Title)-- <br /> (Plot <br /> --------------------------------(Title)_(Plot plan, showing size of lot, location of system in,relefion to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY------------- ------------------------------------ ---------------------------------------------- DATE---------------- ---- --- <br /> - --- ------ ------ ------ <br /> - <br /> REVIEWEDBY-------------------------- -- ------------------------------------------ DATE------- <br /> BUILDING PERMIT - DATE- - f.... <br /> Alterations and/or recommendation ---------­---------------------------------------------- ------------- )4 - <br /> ------------- --------------- --------------------------------- <br /> ---------------------------•---------------------------- <br /> --------------- ------------------------------------ <br /> / <br /> ----------------------------------------------------I--------------------------------­­----------Z--------- <br /> ---------------------------------------------------- ---------- <br /> -- ----------------------------- ------------------------- ----------------------------- ---------------------------------..................... ------------- <br /> ----------------------------- --------------------------------- ----------------------------- ------- ------ ------------------------------------------------------------------------:-------------------- ----------------- <br /> -------------- -- ---------------------------------------- -- -------------------------------------------- -------------------------- ----------------------------------------------------------------. <br /> ,FINAL INSPECTION Date, 100 <br /> - -- --- -- ------ -----------­---------------I---------- <br /> SAN JOAQUIN�LOCAL HEALTH DISTRICT <br /> 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES—3 145846 A7W(JUD <br />