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\ ; <br /> j APPLICATION FOR ANITATION PERMIT <br /> Permit No. ..t�_ "_3. _.... <br /> (Complete in Duplicate} Date Issued 1 / t� <br /> Applica+ion is hereby made to the San Joaquin Local Health District for a permit to constru& and install the work herein described. <br /> This application is made in compliance with County Ordin nce No. 549. <br /> oo <br /> JOB ADDRESS AND LOCATI .,0' --�'--- - _.- <br /> Owner's Name--- - J e <br /> r <br /> 1_3) <br /> / t <br /> Address-------7 - ------------ 1-- J...._ �. <br /> Contractor's Name_.. ------•-- --•-------------- Phone <br /> Installation will serve: Residence <br /> f Apartment House ❑ Commercial ❑ Trailer Court ❑ ,..Moo�tel ❑ Other ❑ <br /> Number of living units: __-L--. Number of bedrooms�. Number of baths __1___ Lot size __. _G�. -.� + ---P <br /> -----•----- <br /> Water Supply: Public system ❑ Community system ❑ Frivate �( Deptn to Wafter Table /0- ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobex Hardpan ❑ <br /> Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic flank or cesspool permitted if public sewer is available within 200 feet.) <br /> Sept' Tank istance from nearest well---------------- Distance from foundation.__. -.Mater iai-------------------------------- --------------- <br /> o. of compartments--------- -------------Size--------._••--------...--------Liquid depth_._.:._........._.__....__Capacity--.------•------.___- <br /> Disposal field: Distance from nearest well_._.- .-Distance <br /> from foundation -10_2.e._.---.Distance to nearest loft line_.___.. <br /> ii <br /> Number of lines-__._......./_ ..._•_-_-- Length of each line------ s� Width of trench------�.'A................. <br /> Type of filter material..S.j -Depth of filter material..J_e........____Total length.______�--�.Q__ -------------------- <br /> Seepage Pit: Distance to nearest•well_____________________ Distance from foundation......_---------.__.Distance to nearest lot line_.__............. <br /> ❑ Number of pits------------------•_--Lining material-...-- __.Size: Diameter------ ......-Depth-•......-.--------_-•_----..... <br /> Cesspool: Distar.ce from nearest well__._____-_-__._Distance from foundation------------- ___.Lining material__.................................. <br /> _ Size: Diameter-------------------------- --- ...-•--_------•-;Liquid Ca acitY•---._.--.: <br /> ❑• Deoth_ P <br /> Privy: Distance from nearest well................:..................... ••-Distance from nearest building­, <br /> tonearest lot line----.................. -----------------------------=-------•---•-------------------------------­--------------------- <br /> Remodel' g and �rierjing,.�(des ri':� '..-•--- ..Gi.•'?►�lel�... _ _ _4_ =--- --•------ --- -• -,..• - - <br /> ----------- <br /> - <br /> .. <br /> - � �=- <br /> I herebycertify that I have prepared this plication nd that the work will be done in a rdance with San Joaquin County <br /> Y <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, <br /> ............((Nner and/or Contractor) <br /> 5► ned _ ............................ --------- ------------------------- ................... <br /> rI <br /> ----------(Title)-..-------------------------------------- ----------------- - <br /> (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY..................................... - ------ --------------•---- -----------------. DATE... ------------....--.--••----•---•--------------- <br /> REVIEWEDBY---------------------.-----------..........- . ..._ :•---------•----•--_--- DATE-- •----.....------------------------------------------------ <br /> BUILDING PERMIT ISSUED................. ...... •--•----- . <br /> -------------- DATE---------------------------------•----•---------•--•----.•_ <br /> Alterations and/or recommends -ons:.. _ /--- ......................... -•-'-•... --- <br /> IQ--- Lk <br /> 1.z- " <br /> ._ `-•• ------------_------._.. ------ <br /> V <br /> s - �_ -------------------- •- ---- --- ----------------------- <br /> ­.. ------- �` <br /> rINAL�SPE TI N BY: Date--------------------- -_--.---.----------------------_------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Sfreet 300 West Oak Street 132 Sycamore Street 814 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />