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F OFFICE USE: lJ„� ,3 �7� ioq ------------ ✓r' APPLICATION FO 1TATION PERMIT Permit No. __�•....... ... .... t -Lam----------------------- - (Complete in Duplicate) Date Issued 9_-1__x_-___� ____ ------ ---------- ------------- This Permit Expires 1 Year From Date Issued d. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein scribes eQ This application is made in compliance with County Ordinance No_ 549. JOB ADDRESS AND LOCATI �- --`--- i Owners Name - ------------ -------- Address----------••-------- - �--�'---�-----��--x--------T--�..�-.-------.>��-�- ------•---�� - ---- - -- - ----- Contractor's Name �� Phone Installation will serve: Residence P' Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __. "- Number of bedrooms --`lumber of baths ___f_ Lot size _____ _____ -- ...... Water Supply: Public system ❑ Community system ❑ Private J4 Depth to Water Table _7,--'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 CK 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____,r-O--Di5fance from f--o-un-d-ation____.,00-Q-__.._.Material___- No. of compartments-----------*Z-----------size.... de th______-_._� --- P Y------ ---- Disposal Field: Distance from nearest well.._ _0-Distance from foundation___.___` --_.Distance to nearest lot line......... Number of lines----------------____ -----------Length of each line..... --------Width of trench------.__ Type of filter material____ Depth of filter material----.__/,fir_---Total length_______________ __C__-tT________ Seepage Pit: Distance to nearest wet "-- Distance from foundation---------__________.Distance to nearest lot - line---_______-______ ❑ Number of pits--- ------------------Lining material----------- ---------Size: Diameter--------------- -- ----Depth------ ----------------------._. Cesspool: Distance from nearest well-----------------Distance from foundation-------- ----------Lining material-_-------.___----___.__- 11 Size: Diameter---------------- ----------- --------Depth----------------------------------------------------Liquid Capacity------------------ gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------------------------. 7 ❑ Distance to nearest lot line------ -- ------------- ---------------- ---------------------------------------------- i Remodeling and/or repairing (describe)------------------ -------------------- --------------------------------•-- -----------------•---------------------------------------------------------- ----------------------- -----------------------------------------------------------•--------------•---•------------•-----------------•------------------------- ---------------•- ---------- ------------------------------------------------------------- ` I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations the San Joaquin Local Health District. - r (Signed)_.--- --�------ - -- --- ---------------------------------- --------------------------(Owner and/or Contractor) --- ---- --"-----------------------------------------------(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------------------ t :-c--n�.�.� ------------ --- DATE--------------- - REVIEWEDBY------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------- ------------------------------------ DATE------------------------------------------------------------ Alteratio an /or recommendations:_______. o-------------- S' �,' - ----�- "'{ .-----•-i ---------.- "- `- i� _1 L •- --- I - -- --- -------- - ------- -------- ----------------------- -r im - �---------- "-.--- --------- -------.—r te------- ------------ •�-- ' ------ ---- -- ------ - � -------- ---- - FINAL INSPECTION BY:------ ------------------ Date----- ----------------- -----------� ------------------------------------- / �� SAN JO?QU1N LOCAL HEALTH DISTRICT �201E.lelton Ave. 300 Westl�ak Street . 124 sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California * _ WW CS 9 REVISED 8-S9 3M 3--r.3 F.P.CD.