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APPLICATION FO,.. ,,,ANITATION PERMIT Permit No. .-__�.7_?---•-- (Complete in Duplicate) Date Issued Applica*ion is hereby made to the San Joaquiri 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 AND LOCATION-•_-- �y_Z, G sa`�` ----- 9 y------ --------------- N -�--`-�- ----- --- - ----- ------------ - Phone--- • ----------�-$d--�•----- Owner's Name-------- ---- -- ---- -- -----••--••-----•------ -yy----------- ------ --------- -- - AddressrS G ,(,6+� - �_ �:.a �-� �r4.V _ -.-� J-1 __ -•----------- Contractor's Nam - - ---•----------- ----------- ----------- ---------- -- --••-- Phone Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms -1----. Number of baths ---i--- Lot size --------I-ih,.r a e.------------------------ - - Water Supply: Public system ❑ i':Community system El Private epth to Water Table -------- ft. ' Character of soil to a depth of 3 feet: Sand ❑ Gravel El Sandy Loam Clay Loam ❑ Clay [I Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 02- New Construction. Yes RJ N, ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------.Material----------------------------------.-------------- QZ�f ��f'I No. of compartments---------- --------- ----Size-------------------------------•Liquid depth-------------------- Capacity------ ---------------- Disposal Field: Distance from nearest well_...............Distance from foundation---__---- Distance to nearest lot line----------------- iAl Number of lines-----------------------------------Length of each line--------.--------------_---- Width of trench Type of filter material-----.--_---------------Depth of filter material -.--------------------Total length-------.---_----------.-_----------_---.. Seepage Pit: Distance to nearest well------ ----------.---Distance from foundation--------------------Distance to nearest lot line------------------ ❑ Number of pits----------- ----------Lining material---------------------.Size: Diameter--- -------------- -.-.Depth--------------------------- --- r Cesspool: Distance from nearest well----------------- from foundation.-.--.-..-------_..Lining material--..-----------.---.----_---------ls Deh� � . -_ Ligui�C�p�ay9a1 ❑ Size4.:Diameter- _ � ----- .__ �� Privy. Distance from nearest well------------------------------------------------Distance from nearest building--------------------------------------- Distance to nearest lot line ------------------- -------• - -------- --••---------------••----••------- ------t---------------------------------- ------------- ------ modeling and/or repairing (describe : �.- - ]_ ------"�'-�'--S 1+� •-----LO.-A-( r--------!-A- ' -111k_ 0 --k_i�------- -------� -- -- '-- r ------------------------------------ --- - -----•------ ------- - - I hereby certify that I have prepared this application and +hat 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. / --- --------N-�-C--------------- ----------------------------------------- (Ow or and/or Contract (Signed)----- d/o -or) -------- — :_-- w .r_ By:----— "¢.�. 4�- ._ ` -. ----------------------- (Plat -------------------- ( } (Plot plan, showing size of�ot, location of system in relation to wells, buildings, etc., can be placed on reverse ide). all FOR DEPARTMENT USE ONLY ' DAT E -.-------------------------------------------------- APPLICATION ACCEPTED BY ------------------------------------------------ --- REVIEWED BY-------------------------------- DATE. `.- - BUILDING PERMIT ISSUED------- ------ --------------------------------------------------------------- ----'------- DATE----- N-----------•--------- ------------------------- Alterations and/or rec mme atio " -.----•-•------------•------------------- ------•------------------------•-----•------------------------•-----------••-----•---------------- J-- �L - "' --------------------------------------------- -------------- ----------------------I---------------------------'---------------------------------------------I----------------------- --------- ------- ---------------- ------------ -------------- J 7 FINAL INSPECTION BY--------------- -- - ------ -------------- Date---------- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C' Street 130 South American Street � Trac California Stockton, California Lodi, California Manteca, California y. �i E'- 9-2M 745446 ATWOOP 12-54