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FOR OFFICE USE: c.I Doos 1!5 r� Z --------------------------------------------------------- APPLICATI N FSR �4NI AA I, P_Rty�IT Permit No. -aZ.O ...�Tc.- ------------------------------------ --- ------ ------ �' f'{C mplete in Duplicate a ` ��' ' rr-.�� ----------------------------- --------------------- This Permit Expires 1 Year From Date Issued Date Issdecl �p ica ion is ereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND L CATION l_._ ____ _______- _-______ -'U`.�-- ......J J i Z111 -- ------- ----------- ---------------------------------------- - --- il-I ; ---------- Owners Name_. . ------- lf_1 _ 1 Phon --•------•------ Address fti.L- Y �� 1 = �- -------- --------• ----•- Contractor s Name--------------- - '' Phone Installation will serve: Residence] Apartment House ❑ Commercial ❑ Trailgr Court ❑ Motel ❑ Other ❑ Number of living units: _I------ Number of bedrooms -----I-_ Number of baths -------- Lot size ____________________--____ Water Supply: Public system ❑ Community system ,kJ Private ❑ Depth to Water Table _s __ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (If yes,date---___--------------) No bi� New Construction: Yeso No ❑ FHA/VA: Yes ❑ No,�5 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest well__��_Id-Distance from foundation___�0_______.Materi L_� 11 `=: . Liquid de th._____-_E� Ca acit !% No. of compartments__-___ ___ __________Size_____ . ____ i/ Dispo al Field: Distance from nearest y�ell_f6f�U_- _.Distance from foundation_Y„�.��Distance to nearest lot line _15 _._. Number of lines.-_.______�_f_- ,��/Length of each line- -D___ r_"_f____- didth of trench_-_��-__________________ /� Type of filter material____{_r1 :Depth of filter material-------J_S.........Total length---------S_'--,---------------------- `O Seepage Pit: Distance to nearest well----------------------Distance from foundation___.................Distance to nearest lot line----------------- o ❑ Number of pits______________________Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------------------__________--_ ❑ Size: Diameter----------------------------- --------Depth-------------------•-------•------------------------Liquid Capacity---------------------------gals. V Privy: Distance from nearest well------------------------------------------------.Distance from nearest building___________________________-________-_- ❑ Distance to nearest lot li ------ --------------------•--------------------- -- ----------------------- ---------------- Remodeling and/or repairing (describe):__-- ----<} 4 ---_'` r-__ ' __ ^- --•-C: _---- _ _,.___��--£----•- ------------- --------------------------------------------------- --------------------------------------------------•----------------------------------------------------------------------------•--•-------------- -----------------------------------------------------------""= ------ 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 o an Joaquin Local Health District. (Signed)----------------------- L -J ---------------------------------------------------------------(Owner and/or Contractor) BY:----------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------- --------------------------------------------------------- DATE------------------------------------------------------------ REVIEWEDBY-------------------------------------------- ------- ---------- ---------------------------------- ------------- BUILDING PERMIT ISSUED.................. ---------------- ----------------------------------------------' DATE_-. -------------------------------------- ------------------ Alterations and/or recommendations------- ------------------ -----------------------------------`---------------------------•-------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------- --------------------------------------------------------------- --------------•----------------------------------------------------------------------- ---------------------------- -------------------------- ------------------ --------------------- ----------------------------- ------------------------------------------------------------------.-_ ----------------------------------------------------------------- --------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY--------------- -- - 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 Manteca,California Tracy,California F.P.❑o.