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FOR OFFICE-USE.- 0. -3. __J ---------------------- ----------- -- - ------------------�. C�---------- APPLICATION FOR �AMfATION PERMIT Permit No. _a -------------------------------------------------- (Complete in Duplicate) I --Permit ------ ------ --------------------------------------------- Expires 1 Year From Date Issued ed -- This P Date Issued _ --. --- --(V Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein desc This application is made in compliancewith County Ordinance No. 549, C(o I- P-0- I a S*1?—I JOB ADDRESS AND.L0CATION__ --------------------- Owner's Name--------- ----------------------------------------------- ----- Address---------- ---------------- --------------- Phon ----------------- --------- A-00 - - -----g-----------------------------------------------------------•-------------------------Contractor's Name----------- R :77- ;01—------------- ---:k 71A --- --------------------------------------------------------- Phone----------------------------------- Installation will serve: 1-1 Residence @T Apartment House El C omme�?cial E] Trailer Court E] Motel E] Other El / *'Ito/ Number of living units. --/-- Number of bedrooms 3.rR.- Number of baths,,?--- Lot - ----------------------------- Wafer Supply: Public system E] Community system [] Private RR000bepfh to Wafer Table aie ft. Character of soil to a-depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loarri'El Clay E] Adobe Zj-'<ardpan E] Previous Application Made: (if yes,date-------------- --- -) No n' New Construction: Yes �To E] FHA/VA: Yes Zjr•No E] TYPE OF INSTALLATION AND SPECIFICATIONS: Distance from founclation--Ap Maferi (No Septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well---_16'a 5602M'' quid depth-_ -----;�/-/-------------Capacityr,_.12007k�l----- No. of compartments-_i ---------------- Si,1_41X Disposal Field: Distance from nearest well--- Distance from foundation---AP--"-_---.Distance to nearest lot line--,,.I- 173 Number of lines------ Length of each line-ARK/-------------- Width of frqn; - Type of filter material_" • -Depth of filter materialAP"'- ----------- -------Total ength'ror Seepage Pit: Distance to riear--4- well.-. cn____,Aa.__----.Di nearest lot�ne%P4F_/------ -- ----- is ance frw fipug6tis -itance to ne. Number of p�fs__ Size: Diam 57 LV'07 --------------Liningmaterial-_,0C efer,;1_17 Cesspool: Distance from nearest well-----------------Distance from foundation-__..__.--.--- ----Lining material__----._..-----_-__._ . / ❑ Size: Mamete"r----------------- - ---------------- -Depth "6------ -----------------------------------------Liquid Capacity al Privy: Distance from nearest well-------------------------------------- i ing------------------------------- -----------Distance from nearest build Ie F-1 Distance to nearest lot line_--______-_____-___-__-____-------_---------------- -- ------ - -------------- - ---------------------------------------------- Remodeling and/or repairing (describe):---------- -- - ----------- ------------------------------------------------- - ---------- -----------------------------------------------------------------------0----------- ----------- ------ ---------------------------------------------------------- ------------------------------------ ------------------------------------------------•--------------------- - --------------------------I ere ---------------------------------------------------------------------------- that I have prepared this application d that the work will be done in accordance with San Joaquin County- 1 hereby certify f pppana ---------------------------------------------- ------------------------------------ ordinances, State laws, anrules and regulations of the San Joaquin Local Health District. (Signed)---------------co�;p -------�_47 ---- ----- ---------- ------------ - - --------------------------- ------------- ---------------(Tit le) ------- - - - ------------- - on (Plot plan, showing size of lot, location of system i elation to wells, buildings, etc., can be paced on reverse side). '0 FOR DEPARTMENT USE ONY APPLICATION ACCEPTED BY- ----------- ---------------------------------- DATE------ R.EVIEWED BY------------------------- ------------------- ------------------ ----- ----- ---- --------- DATE --------------------------------- ----- ------ BUILDING PERMIT ISSUED ----------------------- -------------------------------------- QA'T E--------------------------------------------------C-------- -- Alterations and/or recommendations: ZI---------------- � L ----------- ---------- -----------ciU—------- ------------ C__/ -/ , 4 -j --(�--------------- --------------------------------------------------------------------------*------------------------- ------------------------------------------------------------------------------------------------------------ ------------------ ------------------------------------------------------------------ _;Wn -------------------------------------------------------------_--------------- ------------------------------------I-------------- --------------------- -------------------------- --------------------------- r - ----------------- --------------- ------------------------------------ ------------------ -------------------- --------- "I - ------------------------ --------------------------------- - ------------------------ FINAL INSPECTION BY:-. ----------- ------------------ Date....... --- --------------------- SAN OAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 W s,st Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.Q C3.