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q�`qy APPLICATION FOR -AlNITATION PERMIT Permit No. (Complete in Duplicate) t Date Issued _gra_ys Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicatiori is made in mpliance with County Ordinan No. 549, JOB ARDRESS AND LI ATIO I..____ _ �---_ __� ---------- - ------- ------------ ------------------------------------------- Owner's Name--- . 1 - --------------- --------------a---- ----------------------- ......Phone ==-- - ---- --- Address_.___�_ Contractor's Name--------- _ -- I t------------------------------------ ------- ----- Phone -- ---- Installation 4will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court -❑ Motel ❑ Other ❑ Number of living',units: --- ---- _Number of bedrooms ___e"'_- Number 6f baths Lot size ______ -- 4", x - Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tablel._ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan E] Previous Application Made: Yes [I No New Construction: Yes No ❑ FHA/VA: Yes E] Ns TYPE OF INSTALLATION AND SPECIFICATIONS: _ (No septic tank ci''cesspool permitted if public sewer is available k ifhin 200 feet.) l S r Tan Distance from nearest well__.._-_-__:' Distance from ftiundation--------------------Material _-_______________-___________-___________-_-__. No. of compartments Size '----------Liquid depth--------------------------Capacity------------ t" 1. posal Fi Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot rne------------ ' Number--of lines::_.=_-----'------------------------ L-ength of."each line------------------------------Width of trench-----------------itj Typ.e�-of Iv Type-of filter material----------- ------------Depth of filter mafer;al--------------- T .T al length-____-____________.______--___ -0 ------------ Seepa e:Pit: Distance to nearest well x ,/l2- _ Distance from undatio _ _______ _.Distance to nearest lot line., Number of pits.__._-:______' Lining material ` 'e Size: Dia etor ------------.Depth__�5------- Cesspool.: Distance from nearest wefi-------------- _Distance from found`a""tion" '-"- Liming rriateriel 'Size: _ Nf - F ' ❑ r Distance.Dimeter nearest well ------------'Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy. lt ------------------------------Distance from nearest building----------------------_- Distance to nearest lot line__________________ - ----•--- Remodeling and/or repairing (describe):---- ' ---------------=---------------------------- �' ---------------------- ------------- -----------•-------------------------------•----------•--- ------------------------------- ----- --------------------------•---------------------------- -- ----- ---------------------------- ------------------------------�7------------------------------------ ---- ---------------- I hereby certify that I have pr pare this applic 'n an hat the ark will be done in accordance with San Joaquin County ordinances, S law rules d g tions o t e�Sa oaqui cal Health Di 'ct. f (Signed)---� --- ----- ----- ------(Owner and/or Contractor) - - BY= --------------------------------------------------(Title) - (Plot plan, s 5Z of lo o tion of s em in re a ion to wells, buildings, etc., can be placed on eve side]. 3� FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY------------------------ .r --------------------------------------------------- DATE----------------------- REVIEWED BY = 11 --- �`•----------- ---- - DATE----- 1 - -- ---- -- ------------------------------------------------------- DATE-PERMIT 15SUED_____________� ----__ DATE______. ___�_ __�7-1 --------------------------------- Alterations and/or recommendations:______-______ .___ _____ ---------------------------------------- ------------------------------------------- ----------------- --- --- f ----- --------------- ----- �- ----------------- , r---- - •------- -- ,r^ �� ----- - - - FINAL INSPECTION BY:.__.-.' -- - --- - -en-- -- - Date------ ------------- 7 ��--- - ----------------------- ------------------ 1 SAN JOAQUIN LOCAL ALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California ►i Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.CO. i-.