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FOR OFFICE USE: - - ---------- ! _ _ ____ __ __ ._._ .� -"" ------ APPLICATION Fc R 1NITATION PERMIT ' `" Permit No. . .f...(�.> -------------------------- ------ (Complete in Duplicate) Date Issued Date Issued ___ ��- is Permit Expires 1 Year From D ` 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 compliance with County Ord'na ce No. 549. • JOB ADDRESS AND LOCATION---_____________ -----------------------•------------------------•-------- '------------------ ------•--------------------------------------- Owner's Name ._-• /J? 1------------------- --- ----- ------------------------- --------. Phone.-- -•------------------------------ Address - --- -----r1- -e! Z-- 14eA - Contractor's Name ••-- - -- --- ---,----------------- - - ------. Phone- Installation will serve: Residence [j�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /__ Number of bedrooms _ff-z-2 Number of baths __Z_ Lot size ---;4, _ aZ Q''------------------- t Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table,5-k ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe®'Hardpan ❑ Previous Application Made: (If yes,date_---------__--------) No New Construction: Yes Ywr"No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �J S !' ank: Distance from nearest well_________________Distance from foundation------------------- Material______.._._.______..____.._.___._______.._-____ i +-� ' No. of compartments---------- -- ------------Size--------------------------------Liquid depth------------- ------------Capacity----------------------- I p s I d Ful : Distance from nearest well----___-----------Distance from foundation----------------._..Distance to nearest lot line_______-.__._____ Number of lines---------------- ------------------Length of eachline-----------------------------Width of french----------------------------------- Type of filter material_________________________Depth of finer material-----------------------Total length___._____________-____________--_________ f Seepage Pit: Distance to nearest well { Distanc foundation___ �'_.___.Distance to nearest lot line_.___. Number of pits.----- -----------Lining material-,,r, Size: Diameter----,3 ----_.----_Depth------- 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--------------------------------------------- Remodeling - --Remodeling and/or repairing (describe)-------- --------------------------------------------------------------------•------------------ -----•--------------•-- ----------------------------------------------------------------------------------------------------------------------------------------------- ----------------I------- --------------------- ------ ------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- ------------- ---------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S laws, nd rules an egul 'ons of the San Joaqui Local Health pistrict. � e (Signed)----------------------------- . ....... --- ------ - ---------- ----- - -- --- - --------------------------------------- Own and/or Contractor) BY: x -fir'' ------ (TitEe) (Plot plan, showing size of to+, oca+ion of system in relatio wells, buildings, etc., can be p ced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___.__ .. ___-". -__ _-_ REVIEWEDBY------------------------------- ---- ----------------------------------------- ------------------------------------------- DATE--------------- BUILDING PERMIT ISSUED --------- - ------- - DATE------------ lig -------------------------------- Alterations and/or recommendations------------------- ------------ - --------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- ---------------------- ----------------------------------------------------------------------------------------------•--------- ------------- ------------------------------------------------------------------------------- ----------- --------------- - ---- ------------------ --------- - ------- ------------------------ ---- - -- ------------- ----------------------- ---------------------------- ---- ------------------------ FINAL INSPECTION BY:.......4,�Q --------------- Date---------- ------(O.- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th street Stockton,California Lodi,California Manteca,California Tracy, California