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_ A': ICATION OR iANITATION PERMIT Permit No. 1 t (Complete in Duplicate) 1' Date Issued A i pp ication is hereby made to the San Joaquin Local Health District for a permit to construct and This application is made in compliance with County Ordinance No. 549. install the work herein described. I I JOB ADDRESS AND LOCAiTIO--N '___--- __ _ - --------------------------------------------------- --- ----- -------------------- --- wOwner's Name------------ n -- ----------- -------------------------------------------- Phone Address `,--'[� f ----- - ---�� -----------•---- t ------------- Contractor's Name___________________ - � - -- - =- Phone ---•------------••------ Installation will serve: Residence �� Apartment House ❑ Commercial ❑ Trailer Cour} [] Motel P Other ❑ 1 Number of living.units: J_-__ Number of bedrooms _ " _ ___- Number of baths ___I__ Lot size _"__ -- ---------------------j_— Wafer Supply: Public system "` "� ---""---- ---` PPy y ❑ Community system ❑ Private ❑ Depth to-Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay,❑ Adob,DY Hardpan ❑ Previous Application Made: Yes ❑ No;K New Construction: 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 compartme-nts--------------------------Size------- ------------------------Liquid depth--------------------------Capacity Disposal Field: Distance from nearest well___ Q__- .Distance from foundation----1 Q-----____.Distance to nearest lot line__ -r______ Number of lines---------- y-_l---------------Length of each line_--___ �- _- WidthType filter r p -- - Q --------------------- --------_---__--------- Seepage Pit: Distance to nearest well ❑ Number of pits---- ___Distance from foundation--------------------Distance to nearest lot line----------------- ------------------Lining material----------------------.Size: Diameter----------- Depth --------------------- Cesspool. Distance from nearest welt-----------------Distance from foundation--------------------Lining material-------------------------------------- 0 Size: Diameter--------------------------------------Depth------------------------------- - - --- -------- Liquid Capacity-- ---------- ---------=--gals. (� Privy: Distance -from nearest well-------------------- ------------- --- __--______-Distance from nearest buildingI ` _ x Distance to nearest lot line________________ Remodelfng and/or re airing (describe):-�_�� ---------------------- •---- --------- J'V - '" ✓ `A.�' - ' e n` ---`-J--------------------------------- -------•-------- ------------------------- --------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----------- (Owner and/or Contractor) By:---------=-------------------------•---------- '--------------------------------------- ------------------ Title ------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------____ /__�-�-- } REVIEWED BY �/ DATE------ -- -- A ----- - -- -- ---------- -------------------------------£------- ------ BUILDING PERMIT ISSUED ATE = ------- --- -------------------------------------- DATE Alterations and/or recommendations_________________ ------------------ ----------------------I l ------------------------ ----------------- ---- ------- -- FWAL INSPECTION B ---------- ,--,;_- ,-----,� ------------ Date----- � .: f ! SAN JOAQUIN LOCAL HEALTH DISTRICT l� 130 Soufh American Street 300 West Oak Street 132 Sycamore Sfree+ Stockton, California 814 North ".G" Street Lodi, California Manteca, California Tracy, California E5-9--2M 8-51 Revised W-2100