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t- = FOR=OFFICE USE: =J_?__-e f-------------------- ��--- Permit No. .�_f T r APPLICATION FOR SA`i�ll'�AT,ION PERMIT ------------- ------------------- --------- ---- ---- - (Complete in Duplicate} Date issued .Oz,- _� 4� -------- -- This Permit Expires 1 Year From Date Issued .. q County Ordinance INri 'f ` Application is herebymade to the San Joaquin Local Health [5'strici"f9r a"permit to �nstruct and install the work herein described. This application is made in compliance with Cou y 5 ---------a-6w 5 � k �' ------------------ Phone- p_ U 33- � " ____._._iJOB ADDRESS AND LOCATION------- V � Owner's Name------- �__--___ _ u 11 ! Address----•-•--------------------•------------ --- -----—---------------- -----------------------• --- /- r -- - ---------- Contractor's Name----- ------ ------ 4 �. -•---- Phon 4(0_(9 f ai Installation will serve: Reside e Apartment House, ❑ Commercial ❑ Trailer Court ❑ Motel ❑ /Other ❑ f F Number of bedrooms�. Number of baths__--_-- Lot size ----f---- Number of living units: _.--_+- a k ( Water Supply: Public,system.. Community system ❑ Private El- Depth to Water Table...._- ft. E .E. Character of sail to a depth of 11feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay team ❑ Clay ❑ Adobe} Hardpan ❑ of.} `` No Previous Application Made: (If ye_s,date ��r) No �„�•rNew�Constructiorir: Yes ❑ No" FHA/VA: Yes ❑ TYPE OF INSTALLATION AND ISPECIFICATION5: ' # (No septic tanklor cesspool'Permitted if,public sewer,is.availablewithin 200 feet.) Septic Tank: Distance from;lnearest well-----------------Distance from foundation-------------------Material------------------------------------------------- ❑a<f,t5-0G No. of toma p rtments--------------------------Size----------------- -------------- Liquid depth---- --------------- ----Capacity-------------------J--- -Distance to nearest lot line + Disposal Field: Distance from foundation._. O.---c If ----- ne---Z ...... nearest well_ Nom._Distance from Number of lines,: -�`},--,----,--p Length of each line-.__ # Width of trench_-.2- Depth of filter materiaL___._____f. r(t -Total length___. .__ ----- r Type.of filter mater+aL_).�___�-tea- _ -- �� r I. Seep ge Pit: Distance to nearest wel __ p.Q_ ME�__Distance om f ndation_ DI to nearest lot Gne_ + I_._ _Linin material___ Size: Diameter...- .8___.-.._.Depth--. �._. --T.. Humber of pit �__�- 9 ! ) 4 I Cesspool: Distance from, nearest weld-----------------Distance from foundation------_.__..-----_Lining material_-_-____.._.__._________._.__.-_.____ _:._. ..,.�❑ �..,.,.�.�..�.Size:=Diameter_,..:-.---------------- - ----Depth--------------------- „-----Liquid Capacity----------- ----------------gals. - I a f Privy: ----------------------------Distance from nearest building. _ Distance from nearest,weli__' ___________ i - ." _,�._:_. .•"..ti .. .... ., � � .._.... .�------..�..� ..------------ ---- - ------------------ ------ ❑ Distance to nearest lot line.----- ---------------------------------- ------------------- Remodeling - Remodeling and/or repairing (clescribe)___ _____ _____ _ _.a- .---- --------- -----&-- ----------- ----------- -- --------- -----•---------- --------------------------------------------------------------- - --------------------------------------------- ---------•---------•---------------------------------- ---------f ------------------------------- --------------- hereb certif that I have;I --- ----------- ------ - --- ----------------- - - -- ---------- y y �ped this application and that the wo will be done in accordance.with San Joaquin County ordinances, State laws, and ru s regulations the Sa Joa4inHealfl District. ----- --- _(O e n / r Contract ) (Signed} wn r a o or--------- ------------- ---- - ---- By:--------------------------------- -- +.:- --- -----------(Title)- ----------------- ------- ----- Plot Ian, showing size of lot, location of system in re tion to wells, buildings, etc., can be plat d on reverse side). ( P g � -► f FOR DEPARTMENT USE ONLY f / APPLICATION ACCEPTED BY--- . -------- --------------------- ----- DATE----C - - REVIEWED BY----------------- - --------=- ------------I- -------- ----------- ----------- ------------------------------------ DATE------------------------------------------ ------------ BUILDING PERMIT ISSUED -------=-----••---------------------------------- ----------- - ------------------------- ----- DATE--------------------------- ----------------- -------------- Alteratrns and/or recommend tionsi_________________.------ --------------- -- ------ ------ --------------------- ---------------------- ------------ ---- ------------------------------ - ---------- ------------ ... FINAL INSPECTION BY-------------- - Date---- ------�- ---------- �-------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 west Oak Street 124 Sycamore Street 205 West 9th Street siockton,California Lodi,California Mantecar California Tracy,California I - i F.P.00.