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''FOR OFFICE USE. -'r+i'� ------ ----------------------- --------------------- r, �,2�d - --- --------------- -- ------ - ___ ----------- APPLICATION,,FOIt� 1TATION PERMIT Permit No. .---------------........ ------------ - ------------�-----------------------ii I : (Complete in Duplicate) to }f-4� This Permit Expires 1 Year From Date Issued Date Issued -___.__�__ ___ Application is hereby made to the San Joaquin Local Health District for a permit to onstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. �• %� �/s � —C' � JOB ADDRESS AND LO ATION___ __ ;/ ------- -- -- �� 3 r/` ------------�--/-�-------,-------•---------------- Owner's Name------------ — � ---- Phone .�Y v_ 7 2-- Address-----•------------------------------- 1�j <L` � �� ___Z_---�/i -----•- -------------------•----------- Contractor's Name------------ i--------------------------------------------------------------- •-------- Phone----------------------------------- Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Ot er ❑ Number of living units: ___1_.. Number of bedrooms _. __ Number of baths _I- Lot size � ------------------------ Water Supply: Public system ❑ Community system ❑ Private M Depth to Water Tabled—_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: (If yes,date_______________.. _1 No ❑ New Construction: Yes �o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: # (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Septic Tek: Distance from nearest weli__�D-------Distance from foundation_-_��_.______.Material____ __________________ P gam4 ,[� No. of compartments....__..� _ - ____._..__Size__l�__�_�1"�______,___Liquid de th____________$1_____-----CapaditY------ -------- Disposal Field: Distance,frorn nearest well--- Distance from foundation___10 .__._.. istance to nearest lot line---a.5.--!�___. 21, ._._._ _ Len �" .Width of trench--------- -yam•-------__-•- T ----------------------- e or filter material_ De th of filter material- ..?� Number of lines_________ ___ _-.Length of each line___��- Ty P 1 . Total length ------J Seepage Pit: Distance to nearest well------ ---------------Distance from foundation------_-------------Distance to nearest lot line____.____.__--.. + Number of pits----------------------Lining material.-----------------------Size: Diameter-----------------------Depth'--`-------.---------------------- Cesspool Distance from nearest well_________ .._x._-Distance from foundation------------________Lining material__----------------------------------- I El „-,—Size: Diameter-------------------- ___De th_____..____-- _ __-- Liquid Capacity ---gals. --------------- Distance from nearest building Privy: Distance from nearest well - 9 ❑ Distance to nearest lo# line-' '------------------------------- --- -. - - Remodeling and/or repairing:(describe):---------------—---------------------- ----------------•---------------- ------------------ ---•-------- -------------------------------------------- n r; --------=--'* 1----- �' t ' ------------------------------------------------------- -------------------------- --------------------------------------------------- ------- �: ,. > 7 ! I hereby certify'that I have prepared this application andrthat..the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations df the San„9oaquin,Local Health District. (Signed) --------- - ------- ------- -------------------------------- Owner and/or Contractor BY� ----- ----------------------------=------------------------------------(Title)------------------------- - ---- ----------- ----._......- (Plot plan, sh ing ' g fot, to tion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY { APPLICATION ACCEPTED BY-------------- ---- -- DATE. . 1 -REVIEWED BY-------------------------------------------------6----------- --•-------- ------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----- ---------------------------------------------------------------------------- ----------------- DATE---------------------- ----------------- ------------------- Alterations -------- ---- -Alterations and/or recommendations------------------- -------------------- •- ----------------------- ------------------------------------- ------- ---------------------------------------------------:-------------------- ------------------------------------. ---- -------------------------------------------------------•-------•---------------------- -------...._ ------------ - ------------------- ------- ---------- ------- ----------------------------------- ------------------------------------------------------------------------- -------- ----------------------- -------- //�� rr FINAL INSPECTION BY:.G�. -- !r� Date1rQ - --- - r SAN JOAQUIN LOCAL HEALTH.DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California g, Manteca,California Tracy,California F.F.r.O.