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rUK UrrIC-L USE: nrT --_ z 'y------------------.� `�S ---------------------- ------------------ �_3 c- APPLICATION FOR fSADuplicate) NITcAfi ION PERMIT Permit No. -------- --------------- --------------------- P Ai ) - This Permit 'Expires 1 Year From Date issued Date Issued Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and insfag the-.work:herein described. This application is madein complianc with County Ordinance No. S49. t9 6. JOB ADDRESS AND . LOC_._A._T�O3-N Owner's Name ✓ �� s- -----•------------------------- - Phone_ Addresse ----- ------�•---g-- ----U---•r-s---o----=- - I _ 5 ---------Contractor's Name_______ 30 ----- Phone.. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Motel Other El Number of living units: �_ Number of bedrooms __-Z.-.Number, of baths f Lot size Water Supply: Public system .❑ Community system El Private Depth to Water Tab le-?e?ff. Character of soil to a depth of 3 feet: 1 Sand ❑ Gravel [❑ Sandy Loam a—ti-a-y Loam [] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date------ ---.---------) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ X 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--to- 'Distance from foundation__fQ-" .-_.Materia --ae. .�" No. of comport;en+s----_--'�,� -------Size___- , -_-:---Liquid depth__-,-e,_,!_/- -- Ca acct Disposal Field: Distance from neares well.___ --Dl- ..._Distance from foundation- 4 d� ��- -- �_____ _____Distance to nearest lot line._`_______. � Number of lines__E._ __-- ................Len th of each line __ _� .� _g Y _ -�—' -- ----.Width of trench.p2Y -'-- -------- N l Type of filter mat erial_.-1_I `lrpepth of filter material__I --!---------Total length__`-1-c7D---------------• - 17 u Disfance to neares well.__- _-_______Distance-from foundation----1 '_�-------pistance to nearest to line----.---- Number of pits_-_G___ ______________Lining material__ p.G_ ____Size: Diameter___- 3','_ -.__D�pth _ F I ---------------- Cesspool: Distance from nearest well________________nistance from foundation___--_-_ .--. mmg material_--_____.-._c_____._____________-__. ❑ Size: Diameter. ining material ---- 0 ------,Liquid Capacity-' --gals. c t Privy: Distance.from nearest well-___________________4 _____-._.- _--_.`Disfance from neares# buildin :F. : . g ------------------------------------- Dis�ance #o nearest lot line___ `• l Remodeling and/or repairing fdescribe):-------_ -_ I__---� • -- - ------•-- t�� 1-._ ----------------•-------•------- k_ , -------------- -�__-;_ --------------------- -------- I hereby certify that I have prepared this applica+ion and that the work will be done in accordance with San Joaquin County ordinances, S e ws, and and regulations of the San Joaquin Local Helth District. TTT (Signed)----- -----,-- F .. ------------'~ --- -- --- -- - (Owner and/or Contractor) N -�-'-- Title (Plot plan, showing z of lot, location.of system in relation to wells, buildings,.'etc., can"b' W piaced on reverse' side). i ' FOR DEPARTMENT USE ONLY i 1 APPLICATION ACCEPTED BY______________ - .-_ __-_ , �_ F C S -----------------------`-------------- DATE-----------��- --- REVIEWED BY -------------------------------==-------------- ------------------� ----- DATE__ BUILDING PERMIT ISSUED------------------------------ =- ' DATE - = Alterations and/or recommendations---.------------ � ----- -------- ----- ,• :`0 is •---_--------•------•---•--••---•---------------------------------------•-------- ----- -------------------- n ------------- .,� - _'"'�,.,•�...•---d.�e,trr.--«^-----•,. _..,.� � . - ..-'--- '- ----- ------'- --'------ Date 'FINAL 4NSPECTION BY:----------- -- --------- .... ----- ' 1 ---------- -------------- �`SANIJOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street � 205 West 9th Street Stockton,California Lodi;Cdlifornia Mciteca,California - r I �} Tracy,California E5 9 REV45Ep 8-59 3M 3-•63 r.p•CO�`.`�f