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y r J i 3 APPLICATION FOR S �ERMIT Permit No. (Complete in Duplicate) Date Issued .___/fS-]--- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549, JOB ADDRESS TIQN---- 19 0 --S f Com + 'L_ ' _t_r_-'- --------------- ----------- Phone Owner's Name--- _ -------------- -- -} T _ - ` Address-----------•--------- Contractor's Name1 ----=µ---------------------------------- --------- Phone__,-----------_---------------- Installation will serve: Residence 6 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of Living units: I------ Number of bedrooms __0,_ Number of baths __-_ ___ Lot size ___ _ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ 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___1-.S__'P_-_Distance from foundation_- Q_________..Mat fial--- `x`:-!` -�-L ,r No. of compartments___________ ______ _5ize____.._ Ca acit 9_X_3 S70quid depth--•---- ------- Capacity---,f Disposal Field: Distance from nearest well__ _______Distance from foundation__rrZ0_________.Distance to nearest«lot lire._t„� Number of fines--------------- Length of each Iine---------------- ��_------Width of trench.----r?-_-��---------- ---_ --- Type of filter material _ Depth of filter material___--`_----------Total length.-----12--D------ .--- - --------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------.------------Distance to dearest lot iine---------------- ANumber'of Pits----------------------Lining material__.--------------------Size: Diameter-----------------------Depth-------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-_------------------Lining material----------------------- ___. ❑ Size: Diameter Depth----------------------------------------------------Liquid Capacity-.---------------------�-gals. Privy: Distance from nearest well------_------------------------- ---------------Distance from nearest building--------------------------------- ._____-- ❑ Distance to nearest lot line -------------------- Redeling and/or rpi� (describe): -- -----�------- -- � �------- .--��--. -------------------------------------------------------------------------------------•-- ----- ------------------------------------ -----------------------------------------------------------------------------------------------------------------------•-- -------------------------------•---------------=-------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State�Ilawsd rule an regulafions f t e San Joaquin Local Health District. (Signed(-�--- �� - -- ---------------------- ----------------------------------•---- -------------------------------------------(Owner and/or Contractor) By:---------------------------------------------- ------------------------- -----------------------------------------------------------(Title)----------------------------------------------- --------------- (Piot 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..... DATE------ - --- --- -p--------•------------------- - - - - -- - --- -------------------------------------------- ---- -- --------- -- ---- -- REVIEWEDBY------------------------------ ------------------------------------------•------------- ----- DATE------------------ --------- BUILDING PERMIT ISSUED---------------- ------------------------------------------------------------------- ---------------- DATE------------------- - Alterations and/or recommendations:______. ---------- j Y^'3f_`.y �- `•�:_- --,��_��- c--` -1r--------- E C:r•�c�.:.-�_�-.ta.c�_r. -- .--�� _3,+k ----- ----- 1 �--�1.1.7+------ a -------------------- .d - - --- L f� �- : ---- �-- ------------ -- ----- --- ��~ 6/ • FINAL INSPECTION BY ....... ___--- r Date ------------------------------- 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-9-2M , Revised 1-57 F.RCO.