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FOR OFFICE USE: ---------------------------------------------- ---------- -- ------------------------------------------ APPLICATION FQ.R,SZNITATION 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 woork herein desgrbed. This application is made in ompliance with County Ordinance No. 549. JOB ADDRESS AND LO A 10/ _ J�C.--- 1--+Q . G�,G>s-!'/ - /9---> Sl- --+ f9---___ Owner's Name---------- —.92- ;,------------------------------------------- ---- ---------------------------- ---------- Phone Address---------I ------ ----------- Contractor's Name--------- = f/' ifs---------------------- ------------. Phone--------------------_----------- -------------------------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/___ Number of bedrooms e _.. Number of baths Lot size _-----------------------____ Water Supply: Public system ❑ Community system ❑ Private jR11Depth to Water Table P� ft. p Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam [] Clay ❑ Adobe E] Hardpan Q ` Previous A iica+ion Made: If es,date_________ _______ I 'No New'Coristruction:� Yes -No - FHA/VA: Yes No-� � �» AP l Y Com}" [� ❑ ��' ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I — r o__ {,, Septic Tank: Distance from nearest well-aJ__ _____Distance from found __ ation ,��_._.____. -------------- No. of compartments_..------ -----------S}ze_`.G6_-_1kX—Liquiddepth-=:�_._............Capacity/XjPP------- Disposal Field: Distance from nearest wel %!r ._-___Distance from foundation.- 4y... ._..Distance to nearest to line__ Number of lines %7__ Length of each line___ __� _____________Width of trench--a�_-_----..- ©�' - ------ 9 - �� ------W of filter material__ Z'l� Depth of filter material____-`F___.-_.Total length____�_y_�_________-________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits--- --- ------ --Lining material__._- _ ........... Size: Diameter-------------- --- ....Depth----.----. ---------------------. 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-____..._____..___._________..______� 171 Distance to nearest lot line ,,---------------------- --------------------- - ----------------------•---------------------------------------------------------------------- Remodeling and/or repairing (describe}:-------1[- --�'�d-_-sa .. ---- � ---� �------------------------------ ------------- -----•--------•------------------------------------------------------------------------------------------------------- ------------------------------------ ------------------------------------•------- -------------------- • - - ---- - -- ------ -- -------------- _ r --------------------------------------------------------`-----------'----------------------------------------------------------------------------------------------------------------------'------------------..._..- 1 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) _ 45 r�-�-�---,� � R Y � -----I or'Confe5cto By:--------------------------------------------------------------- --- -- J--------------------------{Ti+le) r�--'-------------- - ............... (Plot plan, showing size of lot, location of sys in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------- -- /-- - - DATE----- -- ----------- REVIEWED BY ------------- - --- - -- ----- ------ DATE----- ---- ------`� ---, BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------- ------------- -------------------- Alterationsand/or recommendations-------- ------ --- ----------- -------------------------••-------------------------------------------------------------- -----------------------------•------- ------------- -------------- ----------------------------- ----------- ---------------- ------------ -- --------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY: lL.�l°`------------- - Date------- -- _- .:�� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 sycamore Street 205 West 9th Street Stockton,California Lodi,California �v Manteca,California Tracy,California