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........... APPLICATION FOR=5AWTATION PERMIT Permit No. .__l.._% � -------------- ----------------------I- ------------- (Complete in Duplicate) G�/ 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. 1 This application is made in complianceCounty Ordinance No. 549, JQB ADDRESS ND LOCATION - --- ---- ------------1/53/.-- - ¢' Owner's Name ---------------------------------------------------------- ------ Phone------------------------------------ Address----- ------------------------------•----Address----- ----------------- ------ -------- -----------•---------------------------------- Contractor s Name--- _.. __.. -- ____ Installation will serve: Residence ❑ Apartment House ❑ CCoommmercial ❑ Trailer Court otel ❑ Other ❑ -, `",. Number of living units: A_0�._ Number of bedrooms,_--Number of baths /�-_ Lot size -__--.4'4-v......_j�! _-------- x N / Water Supply: Public system E] Community systern E]- Private th to Water Table i63�ft. , Character of soil to a depth of 3 feet: Sand ❑ gGravel'❑ Sandy Loam ❑ Clay Loam ❑ Clay❑ Adobe Hardpan [] Previous Application Made: {If yes,date............. .....J No ❑ New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publi sewer is available within 200 feet.) Septic Tank: Distance from nearest well_ of----Distance from fours ation__--.!_Q ----•- .Material-------- °- � ---------- ----- --------- No. of compartments--- ._ _ Sizea`� � �?�_ Liquid depth.... ----------Capacity-*,449it ----.--- Disposal Field: Distance from nearest well.f _.-_Distance from foundon..../40-1-----Distance to nearest lot line----- * Number of lines---f-1 ___ .___A__ ___Length of each Iine/"I'--- - #iidfh of trenc1h_--..M--46:1'____----_{ ( ' Type of filter matenal_ s Depth of fiiter n mateal..__._________ l{ _ o�al length___ Q_�__.�___!'s_A__.___. `-� Seepage Pit: of nearest well_.l_ .� Distance ornllfotundation____�_�_^__.Distance to nearest lot line____ -~- r -- p l-0J------------Lining maferial----------.- Size: Diameter--34- Depth------' `r°------------- i Cesspool: Distance from nearest well________________Distance from oundation-•.._..._-_._--____.Lining material--------------------------..----..__. ❑ Size: Diameter--------------------------------------- --------------------------- Depth---------------------------- ---------------------Liquid Capacity---------- --------------gals. Privy: Distance from nearest well -______-.--_--._---- .____.Distance from nearest building__________-----______________ ❑ Distance fo nearest lot line----------------- , - Remodeling and/or repairing (describe]:----------------------:-- ------------ --------------------------- -------------------•-------------------------•------- ------ ---------------- --------------------------------------- -------- --------------- ------•--•---------------------------- -,Z. = -------- ------ -- ------- - ------ - - --------------- --------------------------------------------------------------------------------- I hereby C tify th + I have prepared this ap i tion and that +he work will be done in accordance with San Joaquin County ordi nce w nd rules d ions o the San J in Local H 1th District. r °o i (Stn - r" 'f �.�..�i- - Contract j }', - - wne or BY ------------------------ g (Title).- ------------------------- (Plot Ti+le)._ _ 1 (Plot plan, showing size of lot, location of system in relation to wells,,buildin s, etc., can be e n reverse Si ). " d r f FOR DEPARTMENT USE ONLY y+ APPLICATION ACCEPTED BY---- - ------ -------------------------- DATE--- ! . - w , REVIEWEDBY----- ------------------------------ ----------------------------- ------ ------------------- -----------------=------ DATE------------- --------------------------------------------- BUILDING PERMIT ISSUED----------------- ---------------------- = - = ---------- DATE-- Alterations and/or recommendations:------ [ ® --- --- d? = '7 �_ _ t - ---------------------------------------- ----- -�----------------------__. — -------- _------- - - ----------------------------- ---------- - FINAL INSPECTION BY:. 4-4 Date x / ; j fw = ---- ------ --- SAN JOAQUIN LOCAL HEALTH DISTRICT�- y 1601 E.Ha:elfon Ave. 300 West Oak Street ,m„ 124 Sycamore Street 205 West 9Th Street Stockton,California Lodi,California ! Manteca, California Tracy,California { e �