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FOR OFFICE USE: ---------------- �: - --------- J _.__..--_-_._.._.!!- =--�""_�--��r_- ---- APPLICATION FOR rSAfdi 'ATION PERMIT Permit No. .__.. }� ----------------- --------------------------------------- {Complete in Duplicate) -- This Permit Expires i Year From Date Issued Date Issued _:: p g r-2-10- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is madem mpliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-:; tQAl Z_--• ---- _�c°✓� ----, T-•---,, l�!/G?.f�J1l---- - �"� n'� -- f Owner's Name-----------------! __b / iQD-S £ GD �� ' .- .-. Phone------ ---------------------------- Address �� ------------•-------------------------------------------------------------- ' ....... Contractor's Name----- • �s_l Phone ff _! ` Installation will serve: Residence ❑Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_.___ Number of bedrooms _cz ._ Number of baths __ate Lot size --------, _ X_... L�______________________ Water Supply: Public system 9KCommunity system ❑ Private ❑ Depth to Water Table-10- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SP'ECIF1CATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet.) t S Septic Tank: Distance, from nearest weU--------------___Distance from foundation-------------------.Material___...___-_-______-._____-_.____-_-.______El _...__. No. of compartments---------- --------------.-Size----------------------------_---Liquid de th_------------------------Ca Capacity ----------------- Disposal _____ Field: Dis-tance from necrest well-----___---______.Distance from foundation--------------------Distance e to nearest lot line_....__________::- ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench------------------------------------ Type of filter material _-.---------------------Depth of filter material----------------------- length------------------------------------------ 0 Seepage Pit: -Distance to nearest well---------------------Distance fr9m foundation_. -!.Distance to nearest lot line-- ----- ___-- Numoerof pits._! l____.______Lining material-- lDC .Size: Diameter-_�_3.7_/ ----Depth-- __-_---_-__-___ Cesspool: Distance from nearest well_-_--------------Distance from foundation-------------------_Lining material--------------------------------------- ❑ -Li Liquid Capacity al Size: Diameter----i - ----------------- - -------Depth----------- - - - - - ------------------- q P Y ----------------- ---•-9 .s. . Privy: Distance from nearest well----------- ---------------------------------------Distance from nearest building___-.-___--_-____-__----____---_--______. ❑ y Distance to nearest lot•line----- ------- ----------------- an Remodelingd irin describe/or,re ap • • 9 I ):---_ ��'+•�-- -4-�- ,!�-C1'_ -.------ -------- �-_I- _? '.11d��---------�..�.��JS?��l�s--------•-• ;_ ------------- ------------------------------------------------------------------ ------------------------------------•---------------------- ---------------------------------------------------- ------I----------------------------- --•---------------------------------------- ----------------••---------------------------------------------------------------- --------------------------------------------- ----------------------------------------------•-•----------------------------------------------------------------------------------------- --------------------------- I hereby certify that I have-prepared this application and that the work.will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-- �a;Pzfo__-- ----- •., .- ---.��V _,!� - ---------------------------------- ---- -----------------�wneand/or ContractorBY: --- ------ .-- -------------------------------------------------------Title)------ .............. (Plot plan, showing size of lot, location of stem in relation to wells, buildings, etc., can be placed on reverse side). i FOR,D.EPARTMENT USE ONLY APPLICATION ACCEPTED BY---.---AA -. --------- -" — ----- DATE------f/_�2--- / --------------- REVIEWEDBY----------------------------------------- -- --- ----- -----------------------------------------•------------ DATE------ ------------•-•------- BUILDING PERMIT ISSUED----------------- ----------------------------- -- DATE------------------- ------------- and/or recommendations:_ -_--_ { _:G_ _L y -----__ /_ �_-_ _ . :��Y/iC' --------r - -•---------------- - - -------- ----------------- ---------------------------------------------•-------- f 1 --------------- ---------------------------------)-------------•---------------•-----------------•--------------- ---- FINAL INSPECTION BY:.. A_. ` Date �f, 7:rSANAQUIN LOCAL HEALTH DISTRICT 1A01 F.Haxslton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California n'