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APPLICATION FOR .�,�ITATION PERMIT Permit No. (Complete in Duplicate) Date Issued . Application is hereby made +o the San Joaquin Local,_Heal#h District for a permit to construct aQd insta t e work herein described. Thi agpli atiorr isd it y�c� wi�unOsr�li nc 5�9. D,, L f .f Uq I 0 J'�I AGI ,cs� "' u _e., „9, AA& � JOB ADDRESS AND LOCATION_---__-.-_-------_--- v [ &Z_ D(po--0 Owner's N e �--� w ------------------- Phone _ Address------- -{------------ L r ---- - -------------------------------- Contractor's Name ---U ' '` -- ------------------------------------ --•--- Phon Installation will serve: , Residence Apar+ment House ❑ Commercial .,� ❑ Trailer Court ❑ Motel ❑ Other ❑ �- Number of living units: -___�_-- Number of bedrooms _-y_ Number of bathe Lot size ------ •_: �•___ r Xnvr �- ----.- Water Supply: Pubic system ❑ ICommunity system ❑ Private Depth to Water Table`"-- t- . .� Character of soil to a depth of 3 fleet: Sand ❑ Gravel ❑. Sandy Loam H Clay Loam ❑ Clay �/ y ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes No Imo" ❑ ❑ 2 ❑ �ew 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___-_-_-- _-_---El -Material --------------- - --- No. of compartments- Weil- - "---------Size------•------------- ------Liquid depth-------------------------Capacity--•-------•------------ ' Disposal Field: Distance from nearest well_ _--------- z - Distance from foundation--------------------Distance to nearest lot line----------------- Type Number l lines_-___-------------=---------------Length of each line------------------------------Width of trench----------------------------------- ---------- of filter material-.---__--- ".-_-------Depth of filter material--------------- i---- ---Total length-------•---------------------------------- Seepage /, #: Distance to nearest well__'1______-f-__---Distance from foundation----/Q----------.Di once to nearest lot line_.`___-___-_• 12 Number of Pits.-._'L_------------_Linin material-- ____- ---[ Lining - Size: Diameter---�-�"---------Depth----- Q ---------------- esspool: Distance from to nearest well________---------Distance from foundation--------------------Lining material------------------------------------- Well -_.--_----_------_ ------------------ - ❑ Size: Diameter = - l ----------Depth------ ---------------------------------------------Liquid Capacity--------------- ----------- gals. j P?riivy: Distance from nearest well _______________________ _ i ------------- -Distance from nearest buildingr^[ "❑ Distance to nearest lot line.-.-_ KJ� Re odeiing and or repairing (describe)------------------------- _ _ _ i ' --- ---------------------------------------- ------- �-�.-.----- --- ------ -------------•-----------------------------------------•-------------- ------------- •----- -- --------------------------- ------------------------ ---------------------------------------------------------------------------------------------------------------------------- -- ------ ! herebycertif that I have � l Y prepared this application and-that-the work will,be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------- -------- (Owner and/or Contractor) ------------ ---- ----------- ---------------------------------------------- -------- --- By:.. A-10-4-nu-- - (Ti+le) - - --------------------- -___----____---_-- -__-- v (Plot plan, showing size o of, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLYy 1 APPLICATION ACCEPTED BY-------------- - ----------------------------- ------------------- --------------- --- ------------ -------------------- ------ DATE--------------- REVIEWED BY--..------------- -------- ------ ------------------------ ---- --�r- - ,r ------- DATE- ------------------------------ BUILDING ----•-------------------• ---BUILDING PERMIT ISSUED - - -----------•------•------------ ------- -------------------------------- DATE-------- Alterations and/or recommendations::__`- - �� �/J �/---------- ------------- ; ------ ::_ --_ _ ::_:--- --:f_ ---- -- FINAL INSPECTI N BY:----- A JOAQ LOCAL HE TH DISTRICT ��- �- 130 South American Street 300 West Oak Street 132 Sycamore Stree 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1-57 F.P.CO� � ��'