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FOR OFFICE ✓ }`_.._ __________. - --------- APPLICATION FOk"IANITATION PERMIT Permit o. /, -------- ----------------- ------------------------------ (Complete in Duplicate) ` ._.:`"� � � •3 ------------------------------------_-._......- This Permit Expires 3 Year From .Date lssued_ Date Issued .... _ App kation is hereby'made 16 the Sbn Joaquin-Locsl'Healfh Distfict-fo`r a permit to construct and install the work herein described. This applicationismade in compliance with County Ordinance No. 544. . ........................... ! JO$ ADDRESS AND LOCATION_ - s �_...._._. .-____.. t? -.-.-•--- � ;f ... ,�. .. - Phone................... ........... OW e"r s Name--- ~- ------ - a' (�._...1 .. .- _ .....f...................................... Address.- J�� 'r'----••• % o j. r Contractor's Name 'J ✓ :.-------•---_--. Phone...................-................ Installation will serve: Residence F] Apartment House [I Commercial E] Trailer Court Mote! E'] Other ❑ r, Number of living units: ,a---- Number of bedrooms -------- Number of baths -------- Lot size ................................'_•------------------------- Water Supply: Public system ❑ Community system ❑ Private [Z Depth To Water Table -------- 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 E] No E] FHA/VA: Yes [I No ❑�^ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r O I Septic Tank: -Distance from nearest well-_44------.Distance from_foundation----rQ_._.._--..Material....--. ?� �._........ No. of compartments-------j---------------Si,4_1" -j!3�'1�Akiquid depth------! -..-----•------Capacity_. �'.� Dispos field: Distance from nearest well_.....�� .�.-Distance from foundation__..../.0----....Distance to nearest lot line.r�!/-_--!_----- Number of lines..-------_ r--- --------------•-Length of each line.AO`__-[-0 -f-.Width of trench----F=-�_------------....--.--_- "F Type of filter material tial =" kDepth of filter material-----/ f�..-------To+al length----- �._�................ ...... Seep, Pit: Distance to nearest well--_-lPj'.--------Distance from foundation-_ _.�.___.i...Distanfe to nearest lot line. .j...._ Number of pits--------/------------Lining material__�UV_ -----Size: Diameter----._� .-------- Depth---- --------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining materia.._.--..--....°.--....._-...__..... r ❑ Size: Diameter--------------------------------------Depth--'---------------------- - -Liquid Capacity------------•-- gals. Privy: Distance from nearest well-------------- -------------Distance from nearest building------------------...--------.---.-------- I ❑ Distance to nearest lot line------------------ ----------------------------------------------------------- -----------------------------------------------•-------- ---- Remodeling and/or repairing (describe)--------- ------------ -----------....---------------•----------------------------------•----------------- ------------------------------------------------------------------------------------------------ --------------------•--------------------------•---- -•-------------------------•----------------•---------------•-----------•----------------------------------------------••------------------•----------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State ws, and rules d regulations of the San Joaquin Local Health District. (Signed)--- -- ------ ------------------ � ran r Contract - BY:------ -- ------ 11 -------•-------------------------- --------- (Plot plan, showing size of lot, location of system-win rel ion to wells, buildings, etc., can be placed on reverse side). FOR DEPART ENT USE ONLY APPLICATION.ACCEPTED BY-- -----•--------- DATE-.: ---------- REVIEWED BY DATE .-------__..w`................ ................... ..... _...-.... BUILDING PERMIT ISSUED-------- DATE--..---._._--_--- --___-- Alterations and/or recommendation' -- --��1�� C --_ •�� - _ - ------ -------------- ------ ---------------------------- - ------------------------ - ----------------------------------------------------- -------•--------............ ------------------ ---------------- -- - -------------. --------------- - ----------- ----------- - FINAL INSPECTION BYE/.��- De+e... ----------- SAN JO UIN LO AL HEALTH DISTRICT 130 south American Street 300 West Oak Street 134 Sycamore Street 205 West 9Th Street 'Stockton,California ladir California Manteca,California Tracy,California Y E5 9 RtVt9tD'a-59 2M 5.62 ATLAS - - �� , sk F ��i,a . � • d -