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FOR OFFICE USE: ---------------------------- --- - --------------------- �. .__ ITATION PERMIT Permit No.-- ----------------- -- ----------------------------------- APPLICATION FOR SAN --------------------------------- ---- i (Complete-in Duplicate) �J Date issued ................... ----------------------.--------- 1 This Permit Expires 1 Year From.Date Issued Application is hereby made to the San5Joaquin 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. JOB ADDRESS AND._ LOCATION_ ---- i ----------- � ------------- ----------------------------------- Owner's Name----- SCJ: ---------------------- ------------- Phone------------------------------------ Address - ------------t Name----- lea �/ C/ 1----- �ouse --- -- . ----- 7 -' �.e.� --- Phone__ _._ p Installation will serve: Residence Apartment Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ... Number of bedrooms -- Number of baths_-A.- Lot size --________________ Water SuPPIY� Publics stem Community system DPrivate e th to Water Table .-- ft Character of soil to a depth of 3 feet•i Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date.-.._............. No New Construction: Yes []1"'No ❑ FHA/VA: Yes ❑ No [ry 0 TYPE,OF-INSTALLATION AND-SPECIFICATIONS: _ • N4i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �� Q� r� Septic Tank: Distance from nearest weEl___._�._..._Distance from foundation___ _______________,Material ----------- No. of compartments 2- _._._.Ca Y--- --Capacity %Z P ---------Size -�4'�€-_S.'.�5--��---Liquid depth----Y- -�---- - P 4------60----------- Disposal Field: Distance from nearest well.....t�Fo-_`___Distance from foundation___rp_'------Distance to nearest lot line------S.`__ Number of lines.---- ,��--..-- -__----Length of each line-- -----��p- -------Width of trench-------A_Y_-~--------------- Type of filter material_____ _____-Depth of filter material--------&..........Total length------... ------------------- Seepage Pit: Distance to nearest well___ 40.�_____-Distance�from foundation___�10_�------Distance to nearest lot line-_-_--4'_�.... Number of pits._--- 2___.__-_._Lining material--Pt V1,cJk___ Size: Diameter._._..,?J?._......... -._.__.__--.- 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 line --------------------------------- --------------------------------------------------------- -------------............. ------------ Remodeling and/orrepairing (describe)-------•------------------------------------ ---------------------------------------------------` ------ ------------ ------------------ - - - -- _... i ----------•---•-------•---------------------------------------- ------------------------- -- _ - ------- -- --------------------- --------------.._..----------------------------------------------------------- - ------- - --------------------- - ------------- - -- -- - i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) �----------- ---- ---- ="`----------------------------- - - y - (Owner and/or,Contractor) -- ---- < .. 1 _ � -----(Title)----- ----- - Plot plan, showing size of lot, location o" f system in relation to wells, buildings, etc., can be placed on reverse side). i P � FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED DATE.-...... /�/'��--------------------- -REVIEWED BY-------------------------------- ---- ---------------_-- -- ----- GDATE----------------------------------------------------------- BUILDINGPERMIT ISSUED.--------------------------------------------------------------------------------------------------. DATE---------------------------------------------- ------------- Alterationsand/or recommendations:..------------ ---------- ------------------------ -------------------------------------------•----•-------------- -------------------•-------------------.. -------------------------- -------------------- I--- ----------------- - - - -------. --•------------------- ------- •- ` `' a - ------------ ---------------------- --------- ------. - ............. - - -------------------------------------- - - - - ------------------------------------------ Date ___` ! FINAL INSPECTION BY:. - ----------- --------------- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 9- 1641 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy,California E.H.9 2M 1.67 Vonguard Press 1�u