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6 3 _ _ <br /> Permit Na. ...... <br /> APPLICATION FOR PERMITI <br /> 1. �� IE {Co plats ui Duplicate) I <br /> - _ � r <br /> 1, Date Issued ----- --------- ---• <br /> Applica�ion 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 co r liance'with County Ordinance No. 549. s <br /> - <br /> _AN CATION-- -- -- ----------- <br /> JOB <br /> ADDRESSPhone <br /> ne <br /> - ----------------------------------------- <br /> Owner's Name-- --------- <br /> ----------------------------------- <br /> ------------------- <br /> - <br /> -- --------------- - <br /> � <br /> - -------------------- <br /> Address_...._ < Phone_ <br /> , <br /> Q -------------- <br /> r - <br /> t tiwr s <br /> Installation will serve: Residence•❑','Apa�iment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Othe <br /> I <br /> ---------------------•- <br /> Number�of living units: ______'Number;of bedrooms:________ Number of baths --------_ Lot,size ____________ __._______..- <br /> 1 � Community,system 6 Private `Depth'to,WaterTable��_ ft. <br /> Water Supply: PuUic'�system'❑ ., Y ❑ <br /> Character of soil to a depth of-3�feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan❑ 0 <br /> Previous Application Made: Yeses'❑ <br /> No <br /> New Construction: Yes No ❑ x_ <br /> TYPE OF INSTALLATION;AND SPECIFICATIONS: <br /> (No sepfie tank or cesspool permitted if public sewer is available within 200'feet.) <br /> Ir <br /> p 'cdTank: l Distance from nearest well_____-__ ___ Distance from faundatsor _____ _:_.Materia__----------____________________________ _ <br /> "- �"""1" .�., "�` Size } F t L�quid depth ----------- ---------Capacity---•----=------- I <br /> ------ - --- ----- _, r field:.: Distance from nearest well__ INo. a compartmen s---_____._li d_iD--_IDistance from foundation_ a�f_----Distance to.nearest lot line___J-__ <br /> Disposal • Width of trench_-___� ___*� <br /> - � �Length of each line::-,�d:-�---------- ---� <br /> ----- <br /> Number of lines---------- -- -'------- g -fi ----Total lent <br /> ► -- 3 <br /> I.... <br /> Type <br /> ___Di sauce from foundation_ `Y�__& ---.Distance tab 1; <br /> T e ort filter materia!-s% <br /> -------- <br /> Depth of filter material_ _8----- T- , <br /> g nearest lot line_________________ <br /> ee a Pit: i. Distance to nearest well__________ _ <br /> Depen <br /> j Number of its.__'__ --"_ - - ---Lining'material----------- ----f-- -Size: Diameter------------------------ , <br /> p ' . P -- -De th- - Lining materiaI *kl. ------ <br /> Cesspool. <br /> ----- is <br /> y. <br /> Cess ool: .. � � Distance from nearest well______.________Distance from foundation.------------ Liquid Capacity________________•_.___._•__._gals. <br /> ❑ Size: Diameter = - <br /> t _ t ----{---Distance from inearest building------------------------------------ ---- <br /> Privy: Distance from nearest well=- ------- ------ -- ---------- - <br /> ❑ 1 = 3 .. a_ ----- - ------- <br /> Ip Distance to'nearest,lot Ime._:_•�: --- ------------ -- <br /> t °I F -------------------- - - <br /> �,. Remodeling and/or repairing (describe}: -° I ----------------------------------------------- <br /> -------------l ------- <br /> --------­---------- ----------•------•--------------•------•-------------- <br /> --'•----------= _ <br /> ------------ , <br /> - prepared application i ------------------------------------------ ------------------------------------ <br /> ------------------ <br /> - <br /> 1 here certif that-1 have re ared this a lication and-thaat fh <br /> - ------- - --------------------------------------------------------- <br /> �� - - k will-be done in accordance with San,Joaquin County <br /> ordinances, Stat laws, and rules-and regulations of the San Joa um Local 1=lealth^District. ' <br /> Y --y-- --• --- - e work <br /> -------------------------- <br /> -- - /or Cont <br /> caner and/or <br /> (Signed) <br /> Y- <br /> -;--- ----- - �------------- --•--- -(Plot plan, showing size of lot, locationopsystem in relation to-wells, buildings, etc., can be placed on reverse side). <br /> FOR.iDEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED BY-------------- -- ------"----------- . i DATE r •, <br /> {J� DATE -------------- <br /> REVIEWED BY-------•------------- ---- - <br /> ,.,.� <br /> ., _ i �-�-- --=-----------=---------------------------------------- DATE---------------------'_-------------------------...__.._..--- <br /> BUILDING PERMIT ISSUED------ ---•---------------------------„ <br /> 1 ------------------- <br /> ------ . <br /> Alterations and/or recommendations---- ------------- <br /> ------------- ----- <br /> -----•----------- -- -----------------•---------------- <br /> ---.--•------- - -- --------------- <br /> ------------- ---------- <br /> • 4 <br /> I -I . <br /> -------------- <br /> I - `---.'. 3------------- --- --- <br /> j ------------ - Date..... = <br /> FINAL INSPECTION BY:.-----------__ -"'- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 300 West Oak Street 132 Sycamore Street <br /> 814 North "C" Street <br /> 130 South American Street Trac California <br /> Stockton, California Lodi, California Manteca, California Y, <br /> .e <br /> ES-9-2M Revised W-2100 <br />