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FOR OFFICE USE: ------------------------------------------------------- -------------------------------------------------------- APPLICATION KiV.SAcNITATION PERMIT Permit No. -�.� --�z -- ------------------------------------------------------- (Complete in Duplicate) _ 3-Z7 ------------------- - ------------------------------ a Issued Date Issued ---------------------- Application -a__._____.__ _ � This Permit Expires 1 Year From Date � 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 Ordinance No. 549- �y JOB ADDRESS AND LOCATION-----------15._ - ---------- R (. --- = f ` --AddOwner's Name---------------------------- b---- �----------------------------------------------- -- - ------- ---------------------------- Phone--- Address------------------------------------------------------------------ ress------------------------------------------------------------------ -------------------------------------------------------•----------------------=------------------------------------------- Contractor's Name--------------------------------------------MIC-0116------------------------------------------------------------------------------ Phone-----•----------.....-----------... Installation will serve: Residence E�t`Apartment House ❑ .Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ___ Number of bedrooms --3-- Number of baths _1____ Lot size ----.-14------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table __/i>ft. Character of soil to a depth of 3 fee+: Sand E] Gravel ElSandy Loam ❑ Clay Loam ElClay ElAdobe B-lHardpan ❑ Previous Application Made: (If yes,date------- -----------) No [ New Construction: Yes to ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: t .(No septic-tank-or cesspool-permitted if-public siwer~is available-within-200 feet:) - 1 Septic T. Distance from nearest well_- f---Distance from foundation-------i P------- Materiaj--------CfX1?�M-_ .._._______- a-_ No. of compartments----------- ----------Size---IR_-'__Y---`-5-_--_---Liquid depth,---------�/.Z....__Capacity-----f' o�--- Disposal Field: Distance from nearest we _5��._Distance from foundation___4P. - _...---Distance to nearest lot he____ (]l Number of lines________________ ______3-_-_____Length of each line------------------------------ of trench_._____a�__._.__________________ Type of filter material--s -_ ?o_-------Depth of filter material___._ ______.__Total length_______,___ ------------------ Seepage Pit: Distance to nearest well----------------------- Distance from foundation--------------------Distance to nearest Iot I'iine__.__________._._ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Deptii--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation---_-----------------Lining material-___.------------. --_._-_ .Size: Diameter--------------------------- ---------Depth--------------------------.----- ------------Liquid Capacity gals. 4. ,.- Privy: Distance from nearest well ______________I--------------------------------Distance from nearest building__---____----------__--_-.-----__-_-___._ ❑ Distance to nearest lot line--------------------------------- ---------------------------------------------------------------------------------------------------------- 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, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------- - _ � r----------------------------- --- -----------------------------------------------------------------------(Owner,and/or Contractor( By:--------------------------------------------------------- ------------------ = ==-----=-_-=------ ---—F---------------- -----(Title)---------- = ------------------------------------------------ (Plot plan, showing size of lot, location of system in relation to wells�u ldings, etc., can be placed on reverse 'side]. FOR DEPART AT USE ONLY APPLICATION ACCEPTEDBY --------------------------- --- -------------------------------------------- DATE-------0_'D1—G2------------� ------ REVIEWED BY------------ ---------- -------- - --------- --------------------------------------------- ----- DATE------------------------- ----------------- ---------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------------._ DATE:------------------------------------------------------------ Alterations and/or recommendations--------------------------------------------------•--------------------------------------------•-------•-----------------------•-I------ --• ----------------- ---------------------------------------------------------------------------------------------------------------------------I--------------------------------------•----------------------------------------------------------- FINAL INSPECTION -- -- - ---- - - ------ ------ - 1!-- ----- .-._ Date.----------Y�---- _',! ------- --�------- ------------------------ S JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ti .- ES 9 R6V,5 EO 9-59 3M 3-'63 F.P.CO.