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c FUR OFFICE USE: <br /> ' ------------- ----------------- ----- - ........ MR <br /> ....---......... ....... . APPLICATION < ANITATION PERMIT Permit No. <br /> ......................... •_._ ......... (Complete-in Duplicate) <br /> .i <br /> This Pe nit Ex ires 1 Year From Date Issued Dote Issued <br /> Application is hereby made to the San Joaquin 1 Health District for a permit to construct and install the work herein described. <br /> hist/applicationris,made-,iriTcompliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION.. 01.4w f Om 1 _ 2 8 U—to <br /> Owner's Name... nn <br /> ��' ...G�- <br /> .���Mt •- ...... <br /> .......... 7 <br /> 'Phone......... <br /> Address........ <br /> - <br /> Contractor's Name..' l-•- .-• ....................... ...........•--•-----_----_- Phone..... •-•........._----•• <br /> Installation will serve: Residence [ ] arfirnent House ._.-I <br /> p ❑• Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living nits: -.(_-_.. Number of bedrooms...2-r. Number of baths•_-.j-._ Lot size ..3l�tTit.._.�• <br /> Water Supply: Public system ❑ Community system ❑ Private WDepth to Water 7eble +.,5-ft <br /> Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam [� Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date..............--... 1 No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No:septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well.................Distance from foundation..................-Material ............._..................-.... " <br /> El <br /> No. of compartments........................_Size.-------.........-•............Liquid depth.......----•- ......... <br /> -......Capacity..... <br /> c I <br /> Disposal Field: Distance from nearest well...i-0A from foundation.j.�' <br /> • - ..........-.Distance to nearest lot line..:....(7..__.. <br /> Number of iines.... .....--. Lengfih of each line.....rj._0-----------------Width of trench- <br /> Al ................... : <br /> `' 1. <br /> Type of filter material._ �. .._:_..._Depth of filter material.-..I.y?........_--.Total length../o-�1..�..........................• <br /> Seepage Pit: Distance to nearest well..... ...`.k.......Distance from foundation....................Distance to nearest lot line.-.,............. 1 <br /> ❑ Number of pits... ..................Lining material.. ........._-- Size: Diameter.......................Depth-............................. <br /> ... . <br /> Cesspool: Distance from nearest well............. Distance from foundation...................Lining material...................................... <br /> ❑ Size. D'iameter--- ------------- .......Depth.....L*..............-••............................Liquid Capacity------------ --------------gals. �3 <br /> Privy: Distance from nearest well............................. <br /> ...................Distance from nearest building................................... <br /> ` <br /> ❑ Distance to nearest loft line-................................ <br /> ,. _................... <br /> Remodeling and/or repairing (describe):-- % + ..... . <br /> .......................................................-•---....................---•••---•--••-•........_..----..._-•--••-----........_...•.......... <br /> .............................................................. .................................................................................................. �-i <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, i <br /> (Signed)------------1! . ..... .... ...-..... - . . <br /> .............. ......_........ ................ -----_--..-.---------..(Owner and/or Contractor) <br /> By:................................-------------_-..........._.............................. -•••------------. f-(Title). .•..... ... ..............._.............._.__ ..._..... ,i <br /> (Plat plan, 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 /> APPLICATION ACCEPTED BY._. .. -rDATE.. <br /> REVIEWED BY <br /> ........... - ................__..................................... .................. DATE <br /> . <br /> ..... <br /> BUILDINGPERMIT ISSUED.............__.............................................................••---.. ............. DATE...........--------•••-• .......-...... q <br /> Alterations and/or recommendations:,................ .............. ................... <br /> .............................................................................................................................................................................................................................. 1 <br /> -----------------------•--•-•----•------.....--•-• ....-------•-------••---•......--••••---• ••-••---•-......_..•------•-•-••---......_.....-••••••••--......•••---•••--...................... g <br /> ..-•-•----•--..._...-----•.............•. ..._....... ..._.....-•----.......---.............----.......--...................... . ...................................................................................... <br /> ........................... ....._................................. ... ..................... ......................................................... <br /> FINAL INSPECTION BY:..."�_ _f. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Masellen Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi.California Manteca,California Tracy,California <br /> E.H.9 2M 1-67 Vanguard Press <br /> . I <br />