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Permit No. <br /> _�APP RMAT-10-N—PER' <br /> SA <br /> APPLICATION FOR <br /> 7 <br /> (Complete in Duplicate) Date 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 49. 0 <br /> VL ATIO -----4ceg ------- ------ --- ---------- -------- - --- -- ------------- ---- <br /> JOB ADDRESS A :--'__ - Pon -------- <br /> ------------ <br /> - ----------------- --- <br /> Owner's Name----------------- _4-------- -- ---- - <br /> Address------------­------- ------------ ------------- w4 -7 <br /> -------- Phone <br /> Contractor's Name Motel 0 Other El <br /> Installation will serve: Residence Apartment House [I Commercial 0 Trailer Court 0 <br /> Number of living units: I_---- Number of bedrooms - Number of baths _ _---- Lot size ----------------------------- <br /> Water Supply: Public system * Community system [I Private 0 Depth to Water Table/K_ ft. <br /> Character of soil to a depth of 3 feet: Sand El Gravel El. Sandy Loam 0 ' Clay Loam 0 Clay [3 Adobex Hardpan E] <br /> Previous Application Made: Yes 0 No �( New Construction: Yes E] No K <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material-------------------------------------------------- <br /> Size--------------------------------Liquid depth.------------------------Capacity----------------------- <br /> e-'-1 No. of compartments-------------------------- ine 0./-------- <br /> aresf well -----------Distance to nearest lot I <br /> Disposal Field: Distance from ne 44,-Distance from foundati( french It <br /> Len gib of each line�14_ of -1- 44 _ <br /> Number of lines-----07-"I 'Y -r <br /> Type of filter material- Iial.... . <br /> K Depth of filter mate; ------------Total <br /> e fo �Size:nD <br /> -./ t line--m-"See a e Pit: Distance to nearest well-_AJOY om ------- Distance to nearest�p%9--- ---Di nc .115- nctliamefei­3 !:? ----------Depth- <br /> _C7XLA7 Lining mat.ri L- V;ZS <br /> Number of pifs-- 1-6—f r_0`m_ro-'n d a f i o n Lining material-------------------------------------- <br /> Cesspool: Distance from nearest well-----------------Distancd Forn tion--______---____.__.Lining -----gals. <br /> 0 Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------- <br /> from nearest building------------------------------------------ Ch <br /> Privy: Distance from nearest well________________________-------------------------Distance ------------- <br /> --------------------- --------------------------------------------------------- <br /> El Distance to nearest lot line------------------------------------------------ <br /> Remodeling and/or repairing (describe):----- 41 j -------- - -- ---------- <br /> -------------------------------------------11------------------I--- ----------- ----------- ---------------------------------------------------------4/-------------------------------------------------- <br /> --------------- <br /> --------------------------------------------- ---------------------------------------- -------------- -------------------- <br /> ---------- ------ --- __ - - -------- -1------- - ---------- ------- ------ ------ --- - ------ -- <br /> ---------I__ <br /> hereby-y certify-- -that- - I__have__prepared- - - __+-his-application- --- - ­and_-that.at__th-e__work-rk__will be done in accordance with San Joaquin County <br /> State AW,S, a -rules and fe6i�ulafions of the an Joaquin Local Health District. <br /> ordinances, S e __a4W_ __j a#/or Conf <br /> -- ----------- ------(Owner., ractor) <br /> -------- --- ------ --------------- <br /> ---- ----- - - --------d_� <br /> _4-------- - -- - ------------- <br /> - ------------- ----- ------- <br /> (Signed)-----------&__ <br /> ----------- <br /> By:----- -A------ - - --------------(Title) <br /> ells, 6 etc., can be plat on reverses', el. <br /> (Plot plan, showing size of lo .4ilocation of system in relation to buildings, <br /> L4 <br /> FOR DEPARTMENT USE ONLY <br /> DATE----- <br /> APPLICATION ACCEPTED BY----- <br /> --------- DATE -- ---- -7------ ------------------------- <br /> REVIEWED BY------------------------------------- ---- ---------------- DATE-_----------------------------- <br /> ------------------------------------------------------- <br /> BUILDINGPERMIT ISSUED-------------------------------------------------------------------------------------- ---------------------------------------------------------- <br /> Alterations and;or recommendations------------------------ ----------------------------------------------------------------------------- --------------- <br /> ----------------------------------------------------------- -- -----------------------------I---------------------------------------------------------------- ----------------------- ------------------------ <br /> ---------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------- -----------------------------------------------------------------I------------------------------ -----------------------------------------------------------------------------------------I <br /> ---------------------------------- ------------------------- ------------------- -------------- --------------------------------------- --------------------------------- <br /> -------------------------------- -------------------------- <br /> -q----h --------------- <br /> FINAL INSPECTION BY---------------" - <br /> Date------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> TracCalifornia <br /> Stockton, California Lodi, California Manteca, California y, <br /> ES-9.-2M 8-51 Revised W-2100 <br />