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�1 `4'� t�1 / APPLICATION FOR 'NITATION PERMIT Permit No. ___ __ _. .......... (Complete in Duplicate) Date Issued _Y3-OA7_ rA,pp5 licafion 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. U ------ P --- -- JOB ADDRESS AND LOCATION_____ __ ____ _. _ � Owners Name_-• Phone_ Address ��tz t�: ,(� ^I =----- _ � __ _ , ---- Co4ractor's Name--- Matehone-------------------- { Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court E] I ❑ Other ❑ Num _/---ber of living units: �___ Number of bedrooms ._ Number of baths ---/-- Lot size _--_— _� ---?(Z `-•J--------------------------- Water •------------ -- , Water Supply: Public system 5� Community system ❑ Private ❑ Depth to Water Table flKr- ft. 1 C1. haracter of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ® Hardpan ❑ Previous Application Made: Yes E] No F1New Construction-. Yes [RINo ❑ FHA/VA: Yes E] No E:1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic,Tank: Distance from nearest wel!________________Distance from folundation--------------------Maferial---__-_____--_-_____________--____--_________. -----Size------------------------- :---Li uid depth-------------------------Capacity------- ------------- No- of compartments � q Disposai Field: Distance from nearest well_---..---______-Distance from foundation___________________Dis#ante to nearest lot line__________..___- ; [%it Number of iines------------------------------- ---Length of each line--------------------------Width oaf -xench-------------------------------•-- Type of`�fili•ermaterial--- --- ----------DEpth of filter material-----------------------Total length-----------------------------•--•--------- 4 ___Distance from f undation-_ -r' -.Distance to nearest lot linel,>�i�- Seepage Pit: Dis#ante to nearest well__( - w r Number of pits-_--------�_-- -__ inmg matersaL-�I�L-- -- _.---.Size: Dia star___ � //pepth Z,S� . -------------------------- Cesspool: •.v" Distance from nearest well-----------------Distance from�ndationn.________--___.__ Lining material__- ____ els. .C. Sze: Diameter Depth------------ ------------<------------*�rLiqui.d Capacity----------------------- g ❑ --- -- r D Distance fromearest buildin ---------------------------------- Privy: Privy: Distance from nearest well------------------------- -- 9 -------------------- Distance to nearest lot Inner"' _."- - ------------------------ ------------------ hRem❑odeli and/or repairing (describe) r2-' -U! ✓�� , 1 I g ---------------------- ----------------------------- t -----'------------- -------------------------------------d� ;P = ------------ I 1 3 '------------ 7 --- .-_ I hereby certify that I have prepaFed this application and that the work will be done in accordance with San Joaquin County ------------------------------------- -------------------- --------------- ---- q ordinances, State laws, and rules and regulations of the Sari Joaquin Local Health District. ___Owner and/or Contractor (Sign ) Y M ------- --------------------------------By (Plot plan, showing site of Potocation of system in relation to wells, buildings, etc., can be placed on rev se side).` --- -- - --�----- --- - -FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------------------------------------------------- --- -------- ------------------------- DATE---------•----------- --�---f REVIEWED BY--------------------------------------------- ------------ ------------- ---------- - -- - DATE--- ----- BUILDING PERMIT ISSUED I ------------ DATE__, ------------- Alterations and/or recommendations:---------------------- - - -- ------- ----- --- •---- ----------------•------------•---- ---------- ---------------------- --- j - - -- -- -- ------ --------------- ( ------ -----••- ---------------- --------------------------------------------------- ------- - ---- - - - -------- w ----------- --------------------- ---------------------- FINAL °INSPECTION BY:._ :___- Date " SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California I ES-9-2M , Rev -1.57 F.P.CO.