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pp w �1 APPLICATION FOR _,,NITATION PERMIT Permit NO. .-O 7 I—__._ (Complete in Duplinate) Date Issued Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. °his application is made in compliance with County Orrd�i,,nance No. 549. JOBADDRESS AND LOCATI N______C�_ r------ ---��€----r3'--�`-----------------------------------• --------•----------------------------------------------- Owner's Name------�- ------101-- d _ _ --- ----------------------------- --------------------------- ------ --------- Phone.•-----_1_4b4.. x Address ~t`- -------------- t_---------------•------._------------------------------------------------------------------- -- -------- Contractor's Name__ 74� ------ Phone ...1..3..--=5.er.5 Installation will serve: Residence Apartment douse ❑ Commercial ❑ Trailer Court ❑Motell ❑ Other ❑ Number of living units: _-if___ Number of bedrooms ._ Number of baths ---I--- Lot size _---_________-_-_________-____ Water Supply: Publics stem �CY Y ommunit system ❑ Private ❑ Depth to Water Table ft. I Y t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Lo;/PNO Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ " Previous Application Made: Yes ❑ No � New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: a (No septic tank or cesspool permitted if public sewer is available within 200 fest.) �,,`� , f � Septic Tank: Distance from nearest weR' _____Dista ce from f yn ation____.__ _ ±____.Mpteria!_ ________ _._ ___.__ _._.. �/ ''L � � E No. of compartments_.-__-_____..______._-_.Size__ _: _ ___.___ _Liquid depth_ ___• -_ ___`._Capacity_____ _ li Disposal Field: Distance from nearest wellW. _"".-----Distance from foundation___-I-----_---------Distdnce to nearest lot �ne_______._____..._ Number of lines......1--------------------------Length of each line----- �`--t, ;j----------Width of trench..__ ,r-._______.________'__ ' Type of filter material---1►-;-F.-.k-________Depth of filter material__-_.l_ ..__._..___.Total length-------- ________________________ Seepage Pit: Distance to nearest well�`_!11_______Distance from foundation___�f .__________-Distance to nearest lot li�e---__-_R_____-V ^ �• 't Number of pits____I_________________Lining mate ria l__U�LC---------Size: Diameter.__ ._._..______Deptri------6. ---- ,—Cesspool: Distance from nearest well-----------------Distance from foundation---_...............Lining material-_______-________.____.____________- `} + i❑ Size: Diameter------ -------------- -r----- --------Depth----------------------------------------------------Liquid Capacity-------_----------•-------gals, f i Privy: Distance from nearest well_ ____________________________-----_-_Distance from nearest building______..______..______________________-_-. ❑ Distance to nearest lot line--------- ------------------- --------------- -------- --•--•--------- ----------------- -----------•-------------- ------------------------- Remodeling and/or repairing (describe):---` ---------------------------- �`t �- �{ c..�„" -• -- ��--z------ -------------------------------••------------------------------------------ -------------------.... `J �- ----------------------------- ------------------------------------ ----- --------------------------•---•- •--------------------------•------------•---••--------------------------------•---------- -•-------------------------------------------- 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 of the San Joaquin Local Health District. (Signed] -- -'------ ---------------------------------- ----------- ------------------------------------ ------ - -----------(Owner and/or Contractor) B -� tion f system in relation to wells buildings, {Titlel--------------- --ti --- '--------••------------ Y� - (Plot plan, showing size at, location y g fc., can be placed on reverse sidJ. ^ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ----------- ----- DATE ------------------------------------------------ REVIEWEDBY-------------------------- ------ -- ---- ---------------------- ------- ---- --------------------------- DATE-- --------------- BUILDINGPERMIT ISSUED------------- --------------------------------------------------------------------- --- =-----._ DATE---------------- Alterations and/or recommendations-------------------------------------r-- ----- ----------------•-------------- ---•---•------------------------------------•---•----- --------- j r ----------• ---------------•------- .....I-------- ---------------•------------- ---------------------------------------------- --------------------------------------------------------------------•----------------------- .r --1 w. FINAL INSPECTION BY-.."04011 --------- Date--------L-- -------------------- --------- ---------------------------------- ------------- SAN --------------------------------. - - 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 ES-9 145446 ATWOQD