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APPLICATION FOR,N TATION PERMIT Permit No. ..... J F ---� emple#e in Duplicate) Date issued _�1--�4 Application is hereby maple to the San Joaquin Local Health District fora ermit to c n I This application is made in.cbmpliance with County rdinance No. 5 p o struct and install the work herein described. JOB ADDRESS AND LOCATION'_ -- _._ f Owner's Name------ •- _ •-��_-_-- � - ----- _ ----------- Address---------- -- • -------------------------------------------- Phone------•----•-- - --•-----•- -- -------•---• ---•- ----------------- Contractor's Name---------- -------------- ---------------------- -•j a -----------------------------------------.__ Phone----------------_--------- ------ Ins+alfa+ion will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court �otel Number of living units: __77 Number of bedrooms � ❑ Other ❑ Number of baths •_�- Lot size _ Wafer Supply: Public sysfem ommunit system 0-"----------- Character Y ❑ Private ❑ Depth to Water Table _ _ Character of sol! to a depth of 3 feet: Sand ❑ Gravelftp ❑ Sandy Loam ❑ Clay Loam ❑ Clay El' Nov El Adobeardpan,❑ Previous Application Made: Yes :- ew Construction: Yes ❑ No ��FHA/VA: Yes No ra TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic fan k'or'cesspool permitted if public sewer is available within 200 feet.) epti Tank: istance from nearesttwell_ a 4�0 ?*.rQistanc f rr� oundaf;on " i<lo, of corn ertments__.__ -. i�I M Leri l e F.e- -------------- Capacity_p �------------------Size_ = Liquid depth p y Dispo Field: Distance from nearest waif-__---___-.-- ' +�------------Ca acit _- __.Lengf Distance from foundation______;________ _-Distance to nearest lot line_._-______- Number of lines---------------------- ------- ----Length of each line------------------------•-_-- Type of filter material________---_--_-_ Depfih of filter material____________ Widfh of trench_____________..__,_..____._.,____ Total length-" - 4s, �e Pit: Distance to nearest well ` � _ --- ----Size: Diameter�Numfaer of pits--------- ------------Lining material.---:-----_-- - ---;stance from foundation________ ___ _Distance to nearest lot line ---Co . Distance from nearest well---------------F-Distance from foundation._---___,----,_-_ .dining material__._.___________-_____ _ ❑ Size: Diameter---- Depth _----Liquid Capacity.__-__---_ Priv - ------ gals. •"1! ------ Privy: from nearest well--------------------------------- I -------- Distance from nearesf building-:____- --_ 'Distance to nearest lot line-_--_ :_'"_ g / _ _ = = •ring (describe):----------- 4 ! ----- / ----------- Remodeling and or repay------------------------ - 4 -•------- ---------- ------------- - I hereby certify fha+ I have prepared this application and fha# fhe work will b- done. ordinances, State laws, and rule and regulations of"the San Joaquin-Local qunr Local Health District. n accordance with San Joaquin Count (Signed) u L.v ` . - .. ika...................... __ Owner and/or Contractor ' (Plot plan, showingsae of lot, loc on of s stem in.relafion to wells buildin s, etc., c {Title)_____ Y an be placed `on reverse e), FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_--------- _�--__-_-_- REVIEWED BY DATE BUILDING PERMIT ISSUED------- ------- ------� -- ---- ----------------------- - DATE------------------ ---- ---- -•-- -'�,---- ------------ --------- - -----Alterations and/or recommends+ions:__-!---------------------- DATE----------•------- -------- ----------- ----- ------•- ----------------- --------- ----- - -----------------------------------------------------------------------------I------------------- ------ FINAL ------------------------------------------ -- -- FINAL INSPECTION�BY::_._ _ ----------- ------ — - Date------- ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street.) Stockton, Ceiifornie 132 Sycamore Street 814 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-21v! Revisacs 1-57 F.RCO.