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APPLICATION FOR NITATION PERMIT Permit No. _ -7------.... (Complete in Duplicate) S//s'� Ap Date, Issued .. -1 --___------- pplication 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. + LOCATION �`V-/ -- i1r� -may.---------- JOB ADDRESS AND L ! Owners ------------- ------------------------------------ Phone_27f.' + i } Address--/'' '-. L. !� � � ✓ ---------------------------------------•--------------•--------- -------------------------------------- iContractor's Name---„[ ----- -------------------•-------•----------------------- Phone-----•-•----•----•----------------- Installation will serve: Residence ❑ partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 0E „ Number of living units: 3--- Number of bedrooms _-3__ Number of baths -- -_ Lot size _-__ ��§__ Y" -------------------------- r t I Water Supply: Public system 5� Community system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AclobeAl Hardpan ❑ Previous Application Made: Yes ❑ No.o New Construction: Yes mss' No ❑ FHA/VA: Yes ❑ No ❑ a , TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearesr well-----------------Distance from foundation--------------------Material------.-------------.__--_------_-----.---_.-.-. No. of compartments--------------------------Size-------------------------------Liquid depth-------------------------.Capacity-_------------------- Disposal Field: ...-------------------DisposalField: D•stance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line------------.-.-- G�i .w,. Number of lines-----'-----------------------------Length of each line------------------------------Width of trench------------------•--------------.- Type of filter material-------------------------Depth of filter 'material---------------.------- otal length__-.__.___---------------_-----__----.-. Seepage Pit: Distance to nearest well - Distance from foundation.022V -.Dist ce to nearest t I ty< c Number of pits------:-.j`__--------_Lining mate ria l__ C1 ------Size: Die meter___- ''_._.ff.Depth Cesspool: Distance from nearest well-----------------Distance from..foundation--------------- LnirtateriaL-.---. _ 1 .. � ❑ Size: Diameter-------------------------=-----•------Depth---- ----------- ---- - -Liquid Capacity-. gals. S� c°< Privy: Distance from nearest welE-------------------------------------------------Distance from nearest building___-----_-.-----_--------_-----------.-_. ❑ Distance to nearest lot line-----_----- Remodeling and/or repairing {describe):-~ til !� _:- `----- ;-_ i u�: f--------------------- -.. z5Z -----------------------------------------------------------------------•-•------- - -------------'' ---------------------------- ----------------------------7 -- =-- --------------------------------------------------------------------•--------------------------------------------------•---------------------:----------------------------------------------------------------------- ------------------------------------------- --------- ------------------------------------------------------------------------------------------ ------------------------------------------------•-------------------- 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) .1 � /------- ----------------------------------(Owner and/or Contractor) . B - ,,� f -�t�---------------- - Title ur `- ! (Plot plan, showing slzeofi lit, location of system in relation to wells, buildings, etc., can be placed on reverse side. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------- --- ------~---------------------------------------------••-------------- DATE-------------------- - -•------------------------------ REVIEWEDBY----------------- --------------------------------- -- ------ ---------------------------------._ DATE------------�, - ---- ------------------- BUILDING PERMIT ISSUED------------------------------- -- ---- -------------------------------------------------------- DATE------ Alterations and/or recommendations:------- ---- ------ - ----------------------------- - ----------------- ------------ a - ------------------------------------------------------' ' -----------------------� --------------------------------- ----------------------------- Y '. ---------------------------- ----------------- < --' l -.. ---------------- ---------------------------------��-� - ---4 r e .....--/-�-------C`'ar�! �"' ----- `` ----- FINAL INSPECTION BY------ ---------- ---------------- -- ------- Date----------- +[VI SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes} Oak Street 132 Sycamore Street -414 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California a ES-9-2 M Revised 1-57 FY CO.