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FOR OFFICE USE: <br /> ------------- --------------- ------------- <br /> APPLICATION FOR'�-SAWATION PERMIT Permit No_ <br /> (Complete- Duplicate) <br /> . Date Issued <br /> ------------ --------------------- ------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to toe San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance. No. 549. <br /> `ff ------------------ <br /> LOCATION JOB ADDRESS A r ..__---.-T _-.7_� .__ "� �-•� � <br /> z <br /> Owner's Name--------------- -------- Phone <br /> -- - - ------- <br /> ------------------------------------------------ <br /> Address_,­-- �� C---- -- - - ----------- <br /> Contractor's Name----- -- - --------------------------------------- --•- Phone------------_-- °----------•------ <br /> i <br /> Installation will serve:. Residence ❑ Apartment House ❑' Commercial 93/Trailer Court ❑ Motel ❑ Other ❑ <br /> i <br /> Number of living units: -_ ,.-!dumber of bedrooms _ Number of baths---/__ Lot size ----- --- -------- ------ <br /> Water Supply: Public system ❑ Community system ❑ Private 2!r Depth to Water Table ------ . ft 1 <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel E] Sandy Loam [:] Clay Loam E] Clay Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date................... ) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: i <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' <br /> Septic ank: Distance from nearest well....AKec�- _-Distance!from i oundation....ly-.........Materiai __ --._ <br /> No. of compartments---__-� _.-__-_.-. .Size_(_ _x _..�h'� Liquid depth.......��--. -_.._-.-Capacity_.�a_ <br /> Dispos Field: Distance from nearest weii---- ------Distance from foundation._-...t�'....---.Distance to nearest lot line-.S_ . ...... <br /> p;� <br /> -----Width of trench.---��------ -------------- <br /> Number of lines-----------�___-___...-_-_______Length of each line------- �_.____ � <br /> Type of filter material--_--.09_).........Depth of filter material-------/.-f...........Total length__-____)_A!sa----------------------- <br /> Seepage Pit: Distance to nearest well---------------------- from foundation-------------------.Distance to nearest lot line:------.---------- <br /> ❑ Number of pits--- ----------.-------Lining material---------------------- Size: Diameter.----------------------Depth_._.. .----------------------- <br /> Cesspool: Distance from nearest well ----------------Distance from foundation____.------------_.Lining material.............-.._-___....__---- d <br /> ❑ Size: Diameter-� --------- ----- ---------- - --Depth--------------- - -------- -------------- ----------Liquid Capacity---------------------- ----gals. <br /> Privy: Distance from nearest weh--------.--_------------------------------------Distance from nearest building---------------------------------- -.-.-. <br /> ❑ Distance to nearest lot line ---------------------------- ------------------------------------ ------------------------------------- ------------------------------- <br /> Remodeling and/or repairing (describe):------- ------------------ - ---------------------------------------------------------•------------------------••--------------------------------- <br /> ------------------- <br /> - --------------------------------------------•--------------------- <br /> -------------------------------------- <br /> ---------- ------------ ------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify—that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State ws, a d rules and regulations of the San Joaquin Local Health District. <br /> .., - ------------------ <br /> $i <br /> (Signed) ----------- - or Contractor) <br /> By---------------- ---- - ----- (Title)---------...--------- ----- ------------------ <br /> ----------- ------------ <br /> (Plot plan, showing size of lot, location of syst m in relati in to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY I <br /> APPLICATION ACCEPTED BY--------- ______ DATE__ �' 6 <br /> ---- ------------------ ---- -- --------- ---------------------- ---- <br /> REVIEWEDBY------------------------- ------------------------------------ ----------------------------------------------- ------ DATE----- -- ------------------------------------------•-- <br /> BUILDINGPERMIT ISSUED-------- -- -- ---------------------------------------------------------------------- - ------------- DATE--------------------------------------------------------- --- <br /> Alterationsand/or recommendations:--- - - -------------------------- --- ---------------------------------------------------------•------------------------------------•------------ <br /> - <br /> Q�-- �}-�p i~ f <br /> - `------ ------ -- --- - ---- Date--- . -------!_-------- <br /> FINAL INSPECTION BY:. ---- ---�_._._`V---- �� � - - --------------------- <br /> SAN <br /> --- - ----SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> :i <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street <br /> Stockton,California Lodi, California Manteca,California Tracy, California <br /> E.H.9 2M 1.67 Vanguard Press <br />