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APPLI'CATI041f FOR.t ANITATION,PERMIT,` Permit No. _` <br /> (Complete in Duplicate) <br /> bate 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 /> JOB ADDRESS A D TION--- _ _--- <br /> Owner's N e --------------------------------------- - - Phone. 1/ Q . <br /> f <br /> Address_:. ------ ---------------- --------- -----------=--- -------------------•----- <br /> Contractor's Name. _ > :r -------------------- one <br /> ------------ <br /> Installation will serve: Residence _ Apartment House? ❑,,rr Commercial ❑]T�r{ailer Court E] Motel C] Other E]Number-of living units: __!-_h_ Number of bedrooms _�4_ Number baths _-__ Lot size <br /> Water Supply: Public system ` Communit s stem T` <br /> PpY� ti I Y ❑, y y '❑'tP.rivafe Depth i s Water Table _______"ft- , <br /> `�•r�r '--�--.,fk' �.�f�-. ^' i� <br /> Character of soil to a�depth of 3.feet:i S;��Ne' <br /> Gravel [❑ tSandy Loam ❑ Clay Loam ❑ Clay ❑-''Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No w Construction:. Yes [vr'No © FHA/VA: Yes ❑ No ®� <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic,+ank or cesspool permitted ifpublic sewer Yis available within 20, feet.)f..' <br /> _rte- <br /> Septic ank: Distance from nearest well*��_.- __[lista afro fo d tion_+-=0__ ri I__A9--z"f <br /> ,No. of compartments .{__.�. ze ax%__.�Liuid glee n - Capacity <br /> _ <br /> t 3 Ft t"from foundatDistance to nearest lot line e <br /> Dispos J Field: NumDistaberr of Inesnce from ___`rest wel ��'�� length of each*ii e____ � ___ _`� Width of trench________ __ <br /> t <br /> Type of filter materi�septh of filter material____.___ - _3,_____Total length___________ __ <br /> Seepage Pit: Distance to nearest well-------------. __'___Distance,from foundation--------------------Distance to nearest lot line----------------- <br /> E Number of pits------#---:`------- Lining meter_ial'--------------------Size: Diameter_-.•------------------Depth--------_-------------_---------- <br /> Cess ool: Distance from:nearest Svell__-___i <br /> i p � '-----_ _ _stance from foundation--------------------Lining material-------------------------------------- <br /> y Diameter '.�..- = = Djpth-----------------------------------------------------Liquid Capacity----------------------- <br /> 0gals. <br /> .. H <br /> Priv D sfanDce from nearest well= __________________ _____Distance from nearest building_.__ __________ ________,_ _______-_- <br /> Distance to line_- _ <br /> ❑ -- - --------------- -- <br /> Remodeling and/or repairing (describe):---------------- 4 2 <br /> �. <br /> ----------------------------------------------------------------------=-- - -----------•--------- <br /> r `t <br /> ---------------- <br /> -------------------------- <br /> -- ----- •-------------- :•-•• ------------------------ <br /> -------- -- -------------------------- <br /> ----------------- - - =- <br /> hereby certify that Ihave•prepared this application an c{ that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and re Mations of the San Joaquin Local.Health District. <br /> 01 J <br /> (Signe ���S ✓5 - <br /> } ,� -------------------------------------------------------------------(Owner and/or Contractor) <br /> �Y= --•--------------------= -------- <br /> ---—--•-------------------------------------­---- ------ •"------- � -------•--- (Title)--- <br /> (Plot -- <br /> -------------- <br /> r (Plot plan, showing size of lot, location-of system in relation to,wells, buildings, etc., can be placed on reverse side). <br /> fOR DEPARTMENT USE ONLY <br /> REVIEWED BY = ' - } `-- : <br /> APPLICATION ACCEPTED BY - ------- 3 =------=-------- ----------------- DATE <br /> - - -------------------------------------- <br /> _ DATE---V-----------• - <br /> BUILDING PERMIT ISSUED------- -- = -" �.... <br /> -- ----------------------------------- <br /> ----------- =---- _ --------------- <br /> Alterations and/or recommendations: r..^►-'"° --------- -----------------------------------------------•-- -..------- <br /> ----------------------------------- <br /> ---•---------------------• ---•--------- -------•--•-------------- --------------- -----------------------------•-=-------------------------------------------- <br /> - - - ------------------------------- •--------------------=----------------------------------- <br /> ------------------------------•------------------- <br /> FINAL INSPECTION BY: `----_-- Date-- � _..- <br /> -------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 Soufh American Streof 300 West Oak Street 132 Sycamore Street 014 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> t <br /> 1 <br /> ES-9-2M , Revised 1-57 F.P.CO. <br /> I - <br />