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FOR OFFICE USE: + No. ------ ------------ ----------------- ------------------ f7 APPLICATION FO �4�iVITATION PERMIT Permi ___ /----------- ------ ------ ------------- -------------- ----------------- - ,(Complete in Duplicate) Date Issued _---------------------------------------- This Permit Expires 1 Year From Date Issued Applicafiion 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. o� --- - JOB ADDRESS AN LOCATION,�� r.---- � � M�c(j -- ------- ---------------------- -------- - -- Owner's Name--------- - -_ -•---------------- ---- Phone. ----•-- r _ _ '_� -4�c ''� � .tt�. .. ---------------------- --------------- ----------- Contractor's Name ----- x Contractor's Name----- ------•----------------•--------------- Phone..----------•-------_------------ Installation will serve: Reside,�ce M. Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot I E] Other ❑ Number of living units: ___. _ Number of bedrooms J___ Number of baths _�__-__ Lot size ____._--Y7d___�' -------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 0-1 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [I Sand L _oam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date -------------------) No ❑ New Construction: Yes ❑ . No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ! No.septic tank or cesspool permitted ifublic sewer is available within 200 feet.] Sep i �TDistance from nearest-well---*_dr___ _Distance 1f�r�om fiioundation-_-_.____________.Materia��__(-�_Y_L-___C_ _________________ r� F I No. of compartments__- I--------- �j Size-0tY.T---�A------..--Liquid depth----- - jCapacity___ F�S------ ---------- Disposal Fields Distance from nearfst well... n.....Distance from foundation___.`f"'o_._-_.Distance to nearest lot line-j0___...... ' �yti/Number of lines__ ______ __-__. _Length of each line-------- of trench___-_. __ _ , IS length -�--- � ------------- --- Type of filter material-- of filter material---------I_ g --------------------°---------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__-___-.___.__.._ ' ❑ Number of pits.---------------------Lining material-----------------------Size: Diameter--------- :------------.Depth--------------------------------- Cesspool: Distance from nearest well-___-_____-___-_Distance from foundation_._._ ---------------_Lining material-..._------______-.__._____________. ` ❑._ Size: Diameter------------------------ ------Depth----_--------__----------. ----- ------- city-----_----_--_-------_---g _ -- . -- -- ____Liquid Capacity gals. Privy: Distance.from nearest well _____------------------------------------------- -Distance from.nearest,building__._.___-_._______----____________-------. i ❑ Distance to nearest lot line- - t-- --------------------------------------,-----------------------------------------------------------------'-------��------- ---------------- =---- ----- Remodeling and/or repj iwng (describe):_ --------------- `±fK -+- , .� __________________________________ --____________________---__________-_____----.-______________-_______---____.---___.______-._----__._ _ ______ __ __ _ ___________________________________ ___ - - , 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. � ---------------------------------------------------------- (Owner and/or Contractor) (Signed)_-- 1_�l ----------------------------------- ------------------------------------------------------------------------------(rifle)---------------- - --------------------- ---- - � '[Plot plan, showing size of lot, location of syatern 'Wrelafioii.to wells, buildings, etc., can be lilaced on reverse sside]. ~" FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY-------------------------------------------------------------------------------------------------- DATE-------------------------- ---------------------------------- ATE----- iREVIEWED BY---------------------------------- ------------------ ---- -------------------- - --- ------ -------- BUILDING PERMIT ISSUED-------------------------------------------------------------------- ------------------ ----------- f DATE----------------=-------------- ----------------------------- Alterations and/or recommendations-------- ------- ------ -------------•------------------------------•---------- ----------------•-----------•------------------------------------- -------------------------------------------------------- ----------------------- -----•----•---------------- -------- --------------------------- --------------------------------------------•--------------.-------------------------------- ---------------------------------- •--------••--------..-----------------------=------------------------------------- -------- -- ----- --------- ------ ------ ----• ------ [/ -�✓ �- - FINAL INSPECTION BY:.. Date----1 j �� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California r, M CS 9 nEv,SEo M-S9 3M 3-'63 F.P.CO.