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/OR OFFICE USE: SSN 07, y. . APPLICATION FOR-SOPERMIT Permit No. •.-. .:....... - ------------------------ (Complete in Duplicate) Date Issued ---,`l0-4 i __---------------._--.----.______--...---.--_.__.-------- This Permit Expires 1 Year From Date Issued 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 made in compliance with County Ordinance No. 549. JOB ADDRESS ANDLOCATION-_ 0--------Z----- ------ - ------ -------------- -- ---------------------------------rJ------- Owner's Name-------- - -/--y - ----� ® 1 -f� _ _ one- - 1 -�E7 Address-_ �� C. �- ------------------------------------------------------------------- -------- ------- Contractor's Name--- - -- - --- -- -- - --- - ------------ ---------- ----- -------- ----------- ------------------ --- Phone.._1/1. Installation will serve: Residence E] Apartment House E] Commercial [I Trailer Court El Motel El Other [� lNumber of living units: -------- Number of bedrooms ----- -- Number of baths -------- Lot size ------/_-----__-__. I Water Supply: Public system ;ff Community system ❑ Private ❑ Depth to Water Table S6 ft. I ' . 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 Vr New Construction: Yes No ❑ FHA/VA; Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) Q' Septic Tank: Distance from nearest weIINOA/t_Distance from foundation_-l.Q- `` -- s-r-- -------.Material-- --- ---+-� -C - - ----- No. of compartments....--_�-` --------Size � X- - ___Liquid depth----- --_ i _ - Capacity-12-00.7N Disposal Field: Distance from nearest well,iViAle_Distance from foundation.A-d.-------e Distance to nearest lot line_---- _A�emvt Number of lines-----_-----�+.- _-.--._Length of each line------- -,7.5--. .Width of trench------- --- ----------------- Type of filter material_- � ,dlG Depth of filter material---e --- -.--.-Total length------ trl_______________/---.--, Seepage Pit: Distance to nearest well-Name..- Distance ff�m foundation-_g- -___..__..Distance to nearest lot line--. � Number of pits----- ,;-------------Lining material-----L,__�J_e-�_.Size: Diameter__.-a,3... Depth----..Z_Z...._--__--_-__ Cesspool: Distance from nearest well----.--.#__-.--Distance from foundation------------------- material--------____--..---..------------.---. ❑ Size: Diameter------------------------ -Depth-------------------------- --------- - -------------Liquid Capacity-- ------------------------gals. Privy: Distance from nearest well-----------------------------------.-------------Distance from nearest building----------------------------------........ ❑ Distance to nearest lot line ---------------------- ------ - ------ -----------------------------------------------------------------------=------------------------ Remodeling /an1d/or repairin (describe)a± d Fly*U �----� �� ' ------° --- /�- 4 ----- r__r f �--..- -/� ------ �!'1-=5----------Sy --------------- ;74/ _ 7_41 =c - - 1 _. a3 � ---------------------------------------------I------------------------------------------------------------- I hereby certify that Dave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regi lations of the San Joa uin Local Health District. t (Signed)------- - -- - -- ---- -- ----- ------- -------- - - -------------------------------------------- (O er and/or Contractor] 13 ----------(Title) ----------------- (Plot plan, showing size of lot, location of system in relatio wells, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ----------------------------------------------------------- DATE--------- d t-'IV------------ REVIEWEDBY-------------------------------- --- ---- - - ---------------- ----------- --------------------------------------------------- DATE---------- ----- BUILDINGPERMIT ISSUED-----------------------------------_.------------------------------------------------------------------ DATE------------------------------ ------------------------------ AI rat' ns and/or recommendations:-------------- -- --- ------------- ------------------------------------------------------------------------------- ® -------- ---------------- ' - - ----- - - ---------- �r - --- ----- - -- ------ - --- ---- f �J FINAL INSPECTION BY------------- = --------- - - ------- ------- - Date--- ------ - - ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 4th Street Stockton,California Lodi, California Manteca,California Tracy,California F.P.CO.