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} FOR OFFICE USE: r-� � q --------------------------------------------------------- APPLICATION FWA—NITAT.ION PERMIT Permit No. ._,1. /---- E ______________________________ ----------------------- 1 J -••----- (Complete in Duplicate)' F�I� ../d................... ---_-._.___._._--____________________________________ This Permit Expires 1 Year From Date issued 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 lir 549. -• ----------- -----•-----....-----•----------------.------ .. ..................... JOB ADDRESS AND LOCATION......... ��f____ __ , -Owner's Name--- ---- - - - --- ------- C ��---------------------- Phone �w Address-------------- l - ----- .••------. . ------------------------------------------------------ ----------••......•._.. v = � --� Phone Contractor's Name._..__.._. _ � ��._ ��__ ..__._ ,��.�.___ Installation will se esidence d_-,N�srtme House ❑ mm r i I ❑ Traiourt ❑ Motel Other CO) Number of living units: ---/. Number of bedrooms -_-4L Number of baths ./-__ Lot size .��..__-------------- lWater Supply: Public system El Community system C1Private [ th to Water Tablet - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ 'Adobe ardpan ❑ Previous Application Made: [If,yes,date___________________) No ew C nstruction: Yes [�]�o LJ- FHA/VA: Yes ❑ No TYPE OF OF INSTALLATION AND SPECIFICATIONS: h (No septic tank or cesspool permitted if public sewer is available within 200 feet.)- S tic Tank- Distance from nearest well_________________Distance from foundation-___tl_____________-Material______--_______________._._.............._....... No. of compartments--------------------------Size.------------.-----------------Liquid depth--------------------------Capacity.....----------------- isposal Fi Distance from nearest well________________Distance from-fl;undation----------..........Distance to nearest lot line................. 0 �❑ Number-of lines______________ ------------Length of each line------------------------------Width of trench _ � -- � Type of filter material------------- . _.._.Depth of filter material_______________________Total length______.____�__�. ._.............. }f i Distance to nearest well,/4 ___ Distance from f ndation ,�._.__..___.Distance to nearest Cot;line-________________ Number of pits___.__ _ Lining material..— _-Size: Diameter___ _____..____.Depth----- Cesspool: e th----- Cesspool: Distance from nearest well___`_________._.Distance from foundation---------------------Lining material................................._._ ') El Size: Diameter------------------------- ------------Depth---•----------------------------- ----------- ----Liquid Capacity gals. . Privy: Distance from near"est well______ ___________________........—---------Distg.nce,from rieorest.building____._ ______ ________-___._:___-___-. I Cl Distance to nearest Tot-line___---________________________ Remodelin and/or repairing es !„ - '- F ._..-.-t_--: _-----------_-••-•- . . .......... ------ --------------------------------- ------------------------- - ------------------------- ----- ,. -------------- - ------------ ------------------------------------------------------------------------------------------------------------- ......--•-- ._ --------•--------------- ------------------ = - ------------ ----- I hereby certify that I have prepared thisapplication d t 't the work will be done in accordance with Sen Joaquir , my ordinances, State laws, and rules d r ulations f the a J cruia Local Hes District. ( '9 ) _.�a. .»_ _ _ (Owne / �ntrector) SI reed__ �^' ''� �' ---- n rC By:• ...........I ----------- -(Title �sidej. � _1 4.buildings, etc., can be plac revers A if" (Plot plan, s o to , ocation o Sys em In relation to wells, Frq R DE ARTMENT USE ONLY APPLICATION ACCEPTED BY-------.......C ---- - --•-'----............-- ---•--------•--- DATE--------L-0-•- --------------.-------•--•--.--.-- REVIEWEDBY... ---•-••----•-•----•----------------- ......................I.---••--------•--- DATE......................... -----------------•-----•-------- BUILDING PERMIT ISSUED..... -------- 4 DA ---------- j AFterations and/or recommendations:_ •I'D-- ' _I_ --- --�----_-•--- - ------ •- --•- ---• -- !••.L..•'--•- .. t7 CI ------- `iz----------- j ''te�/�ZJG¢.t .............. ........... A ----.-`srs .....-.V.-- _ ----•----.�--LYr-Q ' ------ � k -----•------------------------•---_...•--'---..............._.......--•-------------------------------------------------------------------------------------..----•----------------------------------------------------------- FINAL INSPECTION BY..,--............ .. ------------------------------------------ Date----- --------------------- SAN JOAQUIN LOCAL. HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E6 9 nEVISCO 9.99 2M 8-61 ATLAS x