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Permit Na. <br /> APPLICATION FOANITATION PERMIT <br /> (Complete in Duplicate) / <br /> 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 compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND CATION <br /> y ,f ---------------------------------- �--------:-,------------�- <br /> - � <br /> r: � = <br /> Phone Owner's Na _. ----- <br /> essAdd -----------------------•--------`-----------------a-------------------------------------------------- o <br /> - Phe Contractor's Name • ----'------------------------------------------- ------------------------------------- <br /> Installation <br /> - <br /> Installation - fa <br /> will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ____t__ Nu ber of bedrooms _/___ Number of baths __/__ Lot size .__C _ 4"-/Com .._-___ ""_____________ <br /> Water Supply: Public system Community system ❑ Private ❑' Depth to Water Tab]--)/ t. <br /> Character of soil to a depth of 3 feet: Sand ❑. Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> Previous Application Made: Yes ❑ No New Construction: Yesx No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: .Distance from nearest ----------Distance from foundation--------------- Material-----------------------------________.__-_____. <br /> ;. No. of compartments----- --------------------Size------------------------------- Liquid depth---"----------------------Capacity-------------- -------- <br /> Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line.---.-__._______- <br /> ❑ Number of lines-----------------------------------Length of each line-------------------------------Width of trench----------------------------------- <br /> "^ Type of filter material-------------------------Depth of filter material___:-------.-----------Total length-_-__________________________________- <br /> Seepa e Pit: ; �-Distance to nearest well __ _�l�l1_._J___Distance fr m foundation_ J✓.___.___ Distance to nearest lot line___ _____ <br /> Number of pits___._.............Lining material_`-yam" _• . d_.Size: Diameter__=_,_� --------.Depth.__._-_ �_-."__-"______ <br /> Cesspool: Distance from nearest well.................Distance from foundation___.,_,.,__________-Lining material-_._-_--.____.---..-_._____________. �4 <br /> ❑ Size: Diameter----------------------------- --------Depth----------- -- --------------- --- -----------------Liquid Capacity----------------------------gals. <br /> Privy: Distance from nearest well------------- -----------------------------------Distance from nearest buildin ----------------------------------------- G <br /> ❑ Distance to nearest lot line--- ---•---------------- --------------------------------------.----------------------- -"----"---•-------=----------------------- <br /> Remodeling and/or repairing {describe}:----.- - - _-��f`=x^ � ,'. -------- ----• `..-•��4„.--�r_____...1?-------- ------------------- r� <br /> tf -------------------------------------------- ------------ v <br /> --------------------------------------------------------------------------------- --------------------------------------------------------------------------------•-----------------•-•-----------------------•---------=-- <br /> -------•----"----------------------------- --•-----•-----------------------------------:------------------------------------------------------------•-----•----------------------...---------------------------------------- <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State I s, and rules'and regula+ions of the San Joaquin Local Health District. <br /> (Signed) - ----------------------------------- ------------------------------------------------------------ <br /> -(Owner and/or Contractor) <br /> �.C/.-__ Title <br /> SY� - ------------ ( )---- --� I--------------------------------- <br /> (Plot plan, showing size of lot, Iota ion of system in relation to wells, buildings, etc., can be pla verse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------------------- <br /> ------ ----- - -- ---------------•----- •--•----- ----- DATE-------�'------------------------------------------- <br /> REVIEWED <br /> ---------------------------- ---- - <br /> REVIEWED BY DATE_------- e� <br /> BUILDING PERMIT ISSUED----------------------- --- ----------------------------- DATE------ ---- -- - - <br /> --- ------------- <br /> Alterations and/or recommendations:---------- ------- ------------------------------------------ ----------------•-- ----•- -- ------------------------ <br /> __________________________________________________________________________________________________________________________________________________________________________""-__-_---.--__-__________----------------.......­ <br /> ----------------------------------------------------------- -----------------------I------------------- -------------------------------------------------------------------------­­---------------------------------------- <br /> __________________________________________________________________________________________________________________________________________________________________________.___-_-__-_____._____-_-_________-___________________ <br /> FINAL INSPECTION BY:.------- <br /> .......... Date----------- r---------------------------------•------ <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Norfh "C" Street <br /> R Stockton, California ' Lodi, California Manteca, California Tracy, California <br /> SES-9-2M 195446 ATWOOO 12-54 <br />