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�� 5 t APPLICATION FOR' NITATION PERMIT Permit No. (Complete in Duplicate) �� Date Issued ---._. ..._!.?_ ... 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 compiiance withCountyOrdinance No. 5 JOB ADDRESS AND L ATION-- /. �� = -------•------------ 'r Owner's Nam --------- -- Phone._ �f' Address -- ------------------- -- ------- -- -----= --- -- - --------- Contractor's Name-----------.� -----------•-- Phon - •a ® " r Installation will serve: Residence Ap rtment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: ---,1 Number of bedrooms .2— - Number of baths ,__/__ Lot size --- ---------------------------- Water Supply: Public system ❑ Community system ❑- Private Depth to Water Table,eft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ 1 Previous Application Made: Yes ❑ Nox New Construction: Yes No ❑ FHA/VA; Yes ❑ NoI' I TYPE OF INSTALLATION AND SPl CIFICATIONS: • (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septicank: Distance from nearest well_________________Distance from foundation--------------------Material------ ------------------------------ _-____-___. No. of compartments--------------------------Size---------------------------- ---Liquid depth----------------- --------Capacity------------------ e Dispos I geld: Distance from nearest we]-----------------Distance from foundation--------------------Distance to nearest lot line________-____.__- ' Number of lines_______________ --------Length of each line-----------------------------.Width of trench------_-----------------.- ----.--- Type of filter material-------------------------Depth of filter material_____________ otal length-----.__.______________________,_-__..____ Seepage Pit: Distance to nearest well------- ' "___Distance from f ndatio Distance to nearest lot line__ _______ .__________Linin material - Number of pits- _-_al g � Size: Dia eter____-1`- --_------.Depth---.- .-- Cesspool: Distance from nearest well----------------- from foundation---_____ __________Lining material---------------.___'_____._________ N ❑ Size: Diameter-J-1--------------------- Depth= Liquid Capacity gals. Privy: Distance from nearest well------------------------- -----------------------Disfance from nearest building---------------------.-----------_-- „1 ❑ Distance to nearest lot line----- ------------------------- ,�� ______ - g ____________-•Remodeli and/or repairing (describe) _----- _ _ _____ G ; ---------------------•---------------------"---------------------•---------------------------•----------- --- - ---------------------------------------------••-=----------- --------------- ------------------------•-----------------•-------------------------------------------------------------------------------------- I hereby certify that I have prep ed this plicati and that the work will be done in accordance with San Joaquin County ordinances, S to la nd rul s an rguiatio of + San J aquin Local Health District. (Signed)-- --- -- ------- ----------------- - ------ --(Owner and/or Contractor) By:------------------------------ ---- -- --- - ---- -------------------------------(Ti+le)- --------------------------- I(Plot plan, showing size of o , oca on of sy a in re a on to we Is, buildings,etc., can be placed on r vers side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ----- -- DATE------------------e��- -------•-------•----------- REVIEWEDBY------------------------------------ - - -- --- ----------------------------------------------------------------------- DATE---- .... BUILDING PERMIT ISSUED------------- - ---------- ------- ---------------------- ------------------ -- ---- _.-. DA - ----------------------------- ••------- • AI a tions and or commendatia ---------------- --- --- r = •- --------- -- - - - - - - - - - -- -- ---- ----------------- ----------------------------------- ------------ --- ----------- --------------- ----- FINAL INSPECTION BY:-- --- ------'----`--- -- - - - - -- ---------- N --- -.N JO UIN 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—•4-2M Revised 1.57 F.P.CO.