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FOR OFFICE USE: c ij .-....... APPLICATION FOR 9ANIT'7ATION PERMIT Permit No. ------------------- LU_- `- -------- '- ------ (Complete in Duplicate) Date This Permit Expires 1 Year From Date Issued Date Issued �.-4.- j�?.=_ �� Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal! the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION---------------�j�l -4i.�'--S-------------- cai ad - ------------- - Owner's Name----------- ----- - - -•-- A - Phone. Address------------- �7e ----- ---- Q---�--- `'` =--"--------------------------------------------------------------------- s a 3 Contractor's Name- ----------------�--y-�------•--•r-�--�- --- -`�'�..---------------------------------•--•-------------- ----- Phon ------•------------------/ Installation will serve: Residence ❑ Apartment House ❑- Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ------------------------------------------------------------ Water Supply: Public system ❑ Community system ❑ Private ❑ 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 ❑ No ❑ FHA/VA: Yes ❑ 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---------------- ---------Caacit Disposal Field: Distance from nearest well----------- ----Distance from foundation--------------------Distance to nearest lot line----------------- F1 Number of lines----------------------------------Length of each line-----------------------------Width of french---------------------------------- Type of filter material-----------------------.Depth g th of filter material-------------------- -Total length _ _ . .........---.--------------.----- , � r Seepage Pit: Distance to nearest well../,Y.!..____=Disfance fro fou dation.�lf�_..__.Distan�� to nearest lot line.-. ---_--- Number of pits.......: .........Lining material-____ _Size: Diameter------ _._--....Depth--------- , �-------...._ Cesspool: Distance from nearest well-----------------Distance from foundation---.----------------Lining material._-___ --------------------------- Size: Diameter- ---------- ---------- ---------- Depth------------------------------ ---------------------Liquid Capacity----------------------------gals . Privy: - - - -. Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------------------- ❑ Distance to nearest lot line_ ------------------------------- ------------------------------•- ----------------- ------------------------------------------------------ I Remodeling and/or repairing (describe):------ -----/e,CJRt-rr" g---- -c -- ....... ------------ --------------- •-•----•------•------•---------------------------------------------------------------------- ----------------- -------------------------------------------------------------------------- ----- 4 t -------------------- -----------------------.------------ ------------------------------:---------------.-.--•-.____--_--_._..--...-_......---.-.......__•-.-----.-.__._...__.---.-....-_-_-...--------...__._-..-------------- 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. r k (Signed)---------------------------------------------------------- ---------------- -------------------:-------------------•------- ---------------- .(Owner and/or Contractor)_ Sy:---------- ; _ =------------------------------------ ---------- ------(Title)------------------. ------------------- --- - ----------------- (Plot plan, showing size of lot, location o system in relation to wells, buildings, etc.,- can be' placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------ DATE------------------------------------------------------------------------ REVIEWEDBY---------------------------------------- --- ----------- - --------------------------------------------- ------------------ DATE------------------------ ------------------------------- BUILDINGPERMIT ISSUED--------------------------------------`- ----------------------------------------------------------- DATE--------------------------------------- ------------------- Alterationsand/or recommendations----------- ---------------------- --------- - I----------•---------------------------------------- ------------------------------------------------------- - --------------•-----------•---------------------- ---- ---------------------------------------- -----------------------------------------------------------_------------------------- ----------------- r- ------------- ------------------------ - r------------------------------- - /0 J/`� 1 J FINAL INSPECTION BY:--------------��- ------------------•---_- ----- Date -------- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California-i Manteca,California Tracy,California F.F.CC. f,� � rT.