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FOR OFFICE USE: ,. f ---------------- ____---------- _------ APPLICATIONFOR.- PERMIT Permit No. r_-QZ.`.. - .. ----------- • ----------- ----- --- ------ ---------- (Complete in Duplicate) - ____________________..._. This Permit Expires I Year From Date Issued Date Issued _ - _�_ � Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein d scribed. This application is made in compliance with County Ordinance No. 549. JOB 'ADDRESS AND LOCATION_ ---------- -------------------------------- --- -------------- --------------------------•--------- Owner's Name---- � - ------------------------------------------- - -------------------- ----------------- Phone------------• -------------------- ' r -------------------------------- Address -------------- Contractor's Name- - _'e; -------------------------------------------------------------------------------------------------r---------- - Phone----------------------------------- tristallation will serve: Residence ( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I.___ Number of bedrooms _%�--- Number of baths /____ Lot size ------A't�--------------------------- Water Supply: Public system ❑ Community system ❑ Private Afl Depth to Water Table TV ft. t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam.M Clay ❑ Adobe ❑ Hardparl4 Previous Application Made: (If yes,date....................) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - -- Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material_.______________.._----------------------- a . ____. ❑ No. of com artments.._______---_____.__._.Size______________________________Liquid de th__--.--_ Capacity 14-1r � a,?fiP Disposal Field: Distance from nearest well...r _0_...._Distance from foundation___40.____._. Distance to nearest lot Ie_ --------- Number of lines--------/-------------------------Length of each line------ t,, ------------- of trench__ ._V__.---______.______--__ Type of filter materialV_-7__t------.__Depth of filter material----1? -------Total length__ --f,J'—---------------------------- Seepage Pit: Distance to nearest well__ 0 .........Distance from/foundation_,/_'........ Distance to nearest lot line- r Number of pits--- Linin material_ ' -__.--Size: Diameter._ Z3......______.Depth__-_477_-________._______ Cesspool: Distance from nearest weli-----------------Distance from foundation--------------------Lining material____._.__________._______._____.__. ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------.Liquid Capacity- ------------------------gals. Privy:: ------------------------------------------Distance from nearest well-------------------------------------------------Distance from nearest building . Nt R Distanceto nearest lot line---------------------------------------- -----------------------------f-- --------------------------------------------------------------------- Remodeling and/or repairing (describe):------ _-vt---- - --- . ..vz� -------- -------------------------------------------------------------------------------------------------------------------------- -------- -------- ----------/--------------------------------------------------------- ---------------------------------------------------------------------•--------------------------------------------------------------•----------------•--------------------------------------------------------------------- --------------------- ----------- -------------------------------------------------------------•---------------------------------------------------------- ------------------------------------------------ - I hereby ce tifyathat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws; and rules and regulaf' ns f the San Joaquin Local Health District. Si'ned_________._ (Owner and/or Contractor) BY------------------------------------------------------------- ----------------------------------------------------------------------(Title):-------------------------------- ------ (Plot-iplan,'showing size'of lot;location-of system in relation-fo wells, buildings; etc:, can 166-placed on reverse side). �r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ - -�`G s - ------------ - ---- - - - - --- --- ---------�----- ------ ---- -- -- - - -- DATE__-�_-- -- ------ - ---------------------------- REVIEWED BY-------------------------------------------- ----------- DATE--------------------------- BUILDINGPERMIT ISSUED----------------------------------- ------------------------------------------------------------------ DATE------------------------------------------------------------- Alferafions and/or recommendations--------------- ------ - ------- --- ------ - -------------------------------•---•--------------------- -------------•------------------•------------------- 1 f 1 i - -. ---------------- --------------------------�=- =- -- ------------------ - ---------------------------------- ------------------------------------------------------------------------------- - - ---------------- - -------------- -- ---- ----------------------�-r-�---------------------------- --------------------------------- ....-- - - - -------- - ---- - - ----,------..-- FINAL INSPECTION BY------ -------- ------•-------------------- ----•--------------- Date ------------------ ---------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Ho=elton Ave. 300 West Oak Street it; 12,t Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California