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FOR OFFICE USE: <br /> -- -------------- J ,/AITATION PERMIT <br /> --------------------------------- _ .. <br /> .---- ---.-..-------- APPLICATION 1=0R SN ���sermlt No. f_! _rl <br /> ---------=------------------------------------ --------- -in Duplicate) <br /> (Complete �q—�r <br /> Date Issued Ile, <br /> .................... ...............I---------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with Coun#tOrdinance No. 549. <br /> /, <br /> JOB ADDRESS AND LOCA ION.�__ _ ./e" ---_.__ <br /> ------------------------------------------- <br /> Owner's Na <br /> � .... / <br /> ------------------ ------- Phone--------------------•-- - <br /> Address Name r ----------------------------------- <br /> - <br /> ------•------------------------- <br /> -� ....... -•- ------------------------------ Phone---- --------------------------•- <br /> Confiractor's <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercials` Trailer Court ❑ Motel E,?,- <br /> Water <br /> her / <br /> -_ Number of bedrooms ` <br /> Number of living units: �� .•Number of baths_(- ___ Lot size f�C�-_.- _. _ -Su I • Publics stem Community system Private Depth to Water Table ft <br /> pp Y• Y ❑ Y Y ❑� � p <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loamja Clay Loam ❑ Clay ❑ Adobe N Hardpan ❑�` <br /> U <br /> Previous Application Made: (If yes,date-.................. ) No [°] New Construction: Yes ❑ No 'X FHA/VA: Yes ❑ No ❑%& <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation.----------------_ Material ___-_------------_--.------------..-_----------. <br /> ❑ eK%L-%lL* No. of compartments-------------------------Size-------------------- -----------Liquid depth.-------- ------- --------Capacity-----------------------_ <br /> f ! <br /> Disposal Field: Distance from nearest well.!s0_.......Distance from foundation----f_4_.._ .___.Distance to nearest lot line___.I <br /> _�_...... <br /> p�t10oJ Number of lines._-.---__�-------------------------Length of each line-- __��____............Width of french.--_..a_,.._ <br /> Type of filter material_ <br /> ------------------- <br /> T _ <br /> _[ve.Y�._---Depth of filter material----.�.�------- -- ---Total length-------�--------------------------- <br /> Seepages Distance to nearest well----/$Q.---------Distance from foundation-�L_D_r--------.Distance to nearest lot line--- Q-.--_-_ <br /> Su MQ Number of �--P--L.............Lining r�laterial��.e_._ �C1�_ Size: Diameter- ��C__�Q�----Depth....�1--..._.-.-----.---_.-- <br /> Cesspool: Distance from nearest well Q__-_Distance from foundation _A4 ---- Lining material----------------------------_----._. <br /> Size: Diameter- -- -------------- ------------Depth---------------------------------------------------Liquid Capacity. -------------------------gals. <br /> Privy: Distance from nearest well-------- --------------------------- ------------Distance from nearest building---------------------------------..-____. <br /> ❑ Distance to nearest lot line --------------------------------- ------------------------------------ -------- -----•------------------------------------------------------- <br /> Remodeling and/or repairing (describe):------ -----------------_------ ------------------------------------------•---------------------------------------.----- -•---------------------------- <br /> --------------------------------------------'------------- -------------------------------- ---------------- --- --------------------------------------------------------------------------------------------- ------------- <br /> ------------------------------------------------------------------------—------------------------------ ------------------------------------------------------- ------------------------------------------- .... ... ... <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)------------- �� �-�1 , --- - ----- --- ------ -- {Owner and/or Contractor) <br /> By: <br /> (Plot plan, showing size of lot. Iota' n of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> •� FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYE� - ----------- DATE <br /> REVIEWEDBY - --------------......................... ----------------------------------- --- -----• DATE------- <br /> BUILDING PERMIT ISSUED-------- -- ---------------------------------------------------- -------------- ----------- ---------- DATE------------------------------- <br /> Alterations and/or recommendations------------------ -------- ------------------------ -------------------- -------------------------------------------- ---------•- --- ------------------------- <br /> ------------------------------ ------------------­- ----------- --------------------...-------------------------------------------------- ----- ------------------------------------------------------------------- ------ <br /> ------------------------------•----- -------------- --------------------------------------------------------------------------------- ------------------------------------------ <br /> ----- -------------------------------- -------------------- .................. ------ --- ------------------------- <br /> FINAL INSPECTION BY:. .._ �11 ------ ---- - -- ---------- Date............. i ----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Slocklon,California Lodi, California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vanguard Press <br />