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\j APPLICATION FOR ,NITATION PERMIT Permit No. (Complete in Duplicate) 3� Date Issued0 k Applica�ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. is application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--- 7,71- OCATION-- Zd j,..7. .: 3��' Owner's Name-------- --K->----- ' Phone Address -------.-------••------•-•-•----------•-------------------------'•---------------••----•---------------------------------•-------------- ....... - f Contractor's Name__.k.... -_ -�..-'- -- ------ Phone --_-__, Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Wel ❑ ther ❑ . r Number of living units: _._1-. Number of bedrooms ______.. Number of baths ....i--- Lot size ._ J Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _S_ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe 0/ Hardpan ❑ fPrevious Application Made: Yes ❑ No New Construction: Yes V"No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well------------------Distance from,foundation------------_-------Material.._____._-._.__.._____________________-_..__.__-. No. of compartments-------------------- ---Size----=----------------'----- -----Liquid depth---------- ----- ---------Capacity..--------------------- Disposal F" Distance from nearest well...........4__A._Dist ance;fromi foundation-----------------_Distance to nearest lot-line________-___----- Number of lines-----------------------------------Length of each line------ .--------------------Width of trench-,.-------------------------------- Type of filter material------------------------- of filter material---..-------- ........Total length___.-__.._.-._-...__._--.. _..__ Seepag Pit: Distance to nearest well --------Distance from foundation___1_Q-------------Dis ante to nearest loft line----------------- Number of pits...________._______Lining material-_n- ` ......Size: bianieter---. --- -----Depth--. __ _ _ ___________________ 5 --Cesspool: Distance from nearest well-----------------Distance from foundation._.__.__._..__-_--.Lining material-__.__....__;.____.____._____.______- ( s Size. Diameter--------------------- ---..Depth --.----------------------------------------Liquid Capacity __gals. F Privy: Distance from nearest well----------------------------------------------....Distance from nearest building------------------------------------------. ❑ Distance to nearest lot line-------------------'---- ___. ----------------- ! Remodeling and/or repairing (describe):__._ _ . - -- .. .. (._.._ �M-- . ---------------------•--------------------- -•----•-••-------------------------------------------••---•-••-•-----:-------•--------•-----•-------------••------------------------.----•--•----------------------------- r - - - - - - - -------------------•-----------•-------•--. .. .---------- ---------•-••------------------------------------ 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) ' -oy. -rte---- ---- ----- - -----------------•-------------------------------------- Tale ��_`: (Plot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be placed on revers ide). FOR DEPARTMENT USE ONLY l - APPLICATION ACCEPTED BY----- ' ' " ------- ---------------------------------------------------=------- DATE ------------------------------------------ REVIEWEDBY-------------------------------------- ' ' ---' - -------- ---- ----------------------------------------------------- DATE....... 4 .. _ BUILDINGPERMIT ISSUED------------------------------ -- ------------------------------------------------------- DATE---------- ------ Al ations a d/or ret epdations:--------' ' i 1 G ---'----'--- ----------------------------------------------- ---------------------------------- - FINAL INSPECTION BY:.--- S-------------------------------------- Date-'-- SAN JOAQUIN LOCAL HEALTH DISTRICT • 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9 145446 ATWCOD '