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FOROFFICE USE: --------- ------------ -------rR)--------------•---- APPLICATION FOR #011TATION PERMIT Permi+ No. .. .�._-_......; (Complete in Duplicate) s Date Issued ------------------------------------------_--------------_--- This Permit Expires 1 Year From Date Issued ......__.��_.� Application is hereby made to the San Joaquin Local Heal+h District for a permit to construct an i e work h In descriIbed. �. s application is made in compliance with County Ordinance No. 549. JOB ADDRESS A-N CA ION-- - 01? 4__,y'__.�.. .. ,ff- •---- Owner's Name. .. • ------------• ---------------------- - ------- Phone-----••-----'-J--'--c------ -- Address------------ .6 ae -- - - - - ------- - -- --------- -------- -- -- - ---------- J p' Contractor's Name---- ---........ Phone. Installation will serve: Residence it Apartm nt House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___�... Number of bedrooms J-. Number of baths ___�_. Lot size ....� _- _I ........................ Water Supply: Public system ❑ Community system ❑ Private 0 Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobex Hardpan ❑ Previous Application Made: (If yes,date--------------------) 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_________________Distance from foundation--------------------Material................................................. ❑ No. of compartments--------------------------Size--------------------------------Liquid depth-----....------- ........Capacity.................. Disposal Field: Distance from nearest Distance from foundatio _..� ..-.-.-...Distance to nearest lot lins. .:.._.... ❑ Number of lines------------/_____________ __ Length of each line._..._ ?_!------ .---j:_____.Width of trench__ •Z__�e____.______.._..__. Type of filter material-_- L____Depth of filter material..../V----_______Total length..._....��......................... Seepage Pit: Distance to nearest well.._.•_________________Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits-..... .......-------Lining material.,_.-----------------Size: Diameter........................Dept h-------------------..-----.----_ 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---------------------------------------------------------------•--------------------.------ ----•-----••------------------------------------- G u � -Qr repairing (describe)------------------ -- ------ - - ---------`�� ------------....................-----------------•---•.......... ------------------ ................------------------------•-•-----------•-----------------------•-------•------------------------------•------------•------------------------------------_------------------- .....---•-------------------------------------------•--.--•--------------.----.----------------------------••-------------------------------------.....------------...----------------•---------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St laws, and 9#s and regulations of the San Joaquin Local Health District. i (Signed)------ /> - - -------------------- -------------------------------------------------- and or Contractor) By:------------------------------...............................-------------------------------------- -----------------------------(Title)----------------------------------------------- --------------- (Plot plan, showing size of lot, location of system in relation s, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------ -- --- - r_ DATE........ REVIEWED BY----------------------------------------------------------------------------- --` `�-�.-•-----•--------------- DATE-------•--- __./. .... -• ---------------•-------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE----------_-------------------------------------•-------•- Alterations and/or recommendations: ........ ---•-------------------------------•-••--•-------•-------•-----------------------------------------------------.....---................---_.... ----------------------------------------------------------------------------------------------------------------------•-••------•--------------------------------------------------------------------------------•------•----- ---------------------------------- ------------------------------------------------------------------------------------------•----- --......._.._-...-----•-------------------------------------------------------------.-- FINAL INSPECTION BY:. 4-1 = .. Date L,:----------------- --------- _.---- - ---- A� (Y SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 134 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,Colifornla Tracy,California EB 51 REVISED 5-99 $M 8.61 ATLAS