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FOR OFFICE USE: _* ------------------------------------ 3 1 l� � APPLICATION FO _SAhlI1`''ATION PERMIT Permit No. . ...................... -------------------------------------------- -- (Complete in Duplicate) � ----------- This Permit Expires 1 Year From Date Issued 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 County Ordinance No. 549.E _ -79—030-� JOS ADDRESS AND LOCATION._ d 3 �of e-- --- -- i Owner's Name------ �•------ -•----- --------------------------------- - Phone-----------------------•-- Address-----R------/--...... 4x------- 1 ------ ,_A--.---. Contractor's Name-----6',5----•--W",A,!- -.ttz.f------JT^------------------------------------------------------- Phone------------------------ 1 Installation will serve: Residence gR"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r Number of living units: _ _.__ Number of bedrooms _____ Number of baths __j__._ Lot size ---- r ._._ .d.d__F__.____ Water Supply: Public system ❑ Community system ❑ Private Frj- Depth to Water Table RA_ ft. G Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �' Hardpan ❑ Previous Application Made: (If yes,date____________________) No Z New Construction: Yes R ' No ❑ FHA/VA: Yes Z;/ No ❑ , TYPE: OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: DisNot of compartmentsance from }_w.�-�'a_�______Distance from f>f{�f K��})Lin-/--'Liquid dei th_--M�eriaL__�dC raj'-t'�z`� �._-__. � �� f q fP. P Y ��y� Disposal Field. Distance from nearest well..Via._.___..Distance from foundation---/ _.._____._Distance to nearest lot lines.{____________ Number of fines________:L---------------------Length of each line-------114--f-#re_ ----...Width of trench._.__ ---------------------------- Type __ ___..___.________ Type of filter material----/p04_�_____Depth of filter material___I_-______.__._Tota4 length-----j_�--�-----------------------_ �4 - 1 Seepage Pit: Distance to nearest well--f'� --------Distance from f ndation__�-v__(--------Distance to nearest lot line_.._______.. ©- Number of pits_____ - Lining material---e G '---Size: Diameter...YXT........Depth-_--la-------------------------- 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 fine_________________________ �I Remodeling and/or r_epairing�ldesc�ie) ---------------------------------------------------------------------:-----------------------------------_---- ------- - -- -- p ---------------------------------- --- --- -- t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. r (Signed)----------- -- ------ •------------------------------------- ------------------------------------(Owner and/or Contractor) I -B Y•----- Title---------------------------------------:------------------------ ------------- - (Plot plan. showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------=------------------------- DATE------- _/-- ----- ------------- - - REVIEWED BY--------------------------------------------------------------------- ---- ---------- DATE__ - - ----------------------------- - ---- ----------- ------ -- - BUILDI.NG PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:---------- -------------------------- --------------------------------------------------------- -••------------------------------------------------------------ ------------------------------------------------------------------------------ ------- --------------------------------------------------------------------------------------------------------------------- ----------I----------------------------------------------- -------------------------------------------------------------------------------------------•----- ------------------------ ---------------------------------------- FINAL INSPECTION BY:- Date---.--- __---f--� _ { � - - I ' SAN JOAQUIN LOCAL HEALTH DISTRICT r, 1401 E.Hazelton Ave. 300 West Oak Street ,X124 Sycamore Street 205 West 9th Street Lodi, California F Manteca,California Trac Stockton,California Y,California F.P.CO.