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FOR OFFICE USE: APPLICATION FOR SAN PERMIT Permit No. _..`rr�.f ....... (Complete-in Duplicate) nate Issued _._� .. - This Permit Expires 1 Year Froin Date Issued --- --------- --------- --------------- ----..__. --- -g _- Application is herebymade to the San{Joa uin Local Health District for a permit to construct and install the work herein described. This application is made in compiiance�with County Ordinan e, No. 549• 4 R- �' '-------------------- JOB ADDRESS AND �WA ION - -- --------- --- Owner's Name-- _ ------- Phone / l=!• 3� p -------- -- - -- --- --d Address------------------------ - --- ---------- - ( - / PhoneA �y - C -G.f-..� r� Contractor's Name `t` ----- - - ------ ---------------------- Motel ❑ Other Installation will serve: Residence {�. Apartment House El Commercial ❑ Trailer Court El Motel --__ Number of bedrooms _3-_ Number of baths_ Lot size .- Number of living units: __ - Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table7.5. . ft + Adobe Hardpan Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ A ❑ Previous Application Made: (If yes,d __. ate .-____-,--...__ ) No V.New Construction: Yes ❑ No �-FHA/VA: Yes ❑ No i 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..-.----------------__-.--..____..___-___...__.. ❑�t�iSIN y No. of. compartments---------- -----------I---Size--------- -----•---- ----- -----Liquid depth ------- --- -- ------- Capacity_..--- .: Disposal Field: Distance from nearest well......-....__---Distance from foundation__.___ __Distance to nearest lot line.-------------- Disposal Number of lines.----------------------------- ----Length of each line--------- --.Width n trench / Depth of filter material_--- ____Total length_._._---------------------------------- -� l Type of filter material___________________...- p ------ - - r - -_____-.---Distance to nearest lot line--2s..... 4 Seepage Pit: Distance to nearest well..�a2__.. Distance om undation_.�� Number of pits.QJ�74 Lining material__---- Size: Diameter.¢211--------Dept h --------------- ----- Cesspool; Distance from dearest well ----------------Distance from foundation- ------- ..Lining material-_-..__._._- ------ els- ❑ Size: Diameter. .. - -------- ------Depth--------- ------------------ -------f -------------Liquid Capacity.- ----------- - - -- 9 Q stance from nearest well--------------------------------------- -- i?istance from nearest building________________ Privy: Di _ ._____--_---.---------- �. ❑ Distance to nearest lot line ..------------------c---- ------ -- ---------- - ------------------------- Remodeling and/or repairing (describe):__._ -------- E --------------------------------------------------------------------- --------------------------------- ---- ------------ ------------------------------------ } 1 hereby:certify that ve prepared this application and t the work will be done in accordance with.San Joaquin County ordinances, State laws, nd ules and reg tions of the San J quip Local Health District. � T I` (Signed) er----------------- and/or Contract -- ----- --------- or] Si ned --------------- _ .. --- ---- - ---- -- -------------- (Plot plan, showing s loot, location of system in relation to wells, buildings, etc., can be placeJ4n reverse side). FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY i-. _. __ ----- ----------------------------- -------------- DATE----- - ",= �Z /-."'.1 ------------ ------------ DATE----- --------------- ------------------------------------- REVIEWEDBY--------------------------------------------- _------- ----------- ----------- ------------- ---- DATE- - -----------11----------------------------------------- BUILDING PERMIT ISSUED-------- --------- -------------------------- --------------—----------------- --------- Alterations and/or recommendations:------------------------=----------- -------- - ----------- -----`-------- ---------------------------- ----------- --••--------------------- •----•------------ -------•---------- ------------------ -------------------------------- ----------- - --------------------------------- -- `FINAL INSPECTION ----- Date__...,, � -------------- SAN - - ----- - t - - �- ��- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 Weal 9th Street Stockton,California Lodi, California Manteca,California Tracy,California E.H.9 2M 1.67 Vanguard Press f�