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1?I14 ✓ . fT�� -y I APPLICATION FO ANITATION PERMIT Permit No.R 1 __. 91-1 � (Complete Duplicate) y Date Issued ------`-- r ` 3 Application is hereby made to the SaniJoaquin 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. I JOB ADDRESS AND LOCATION------t{--- --------------- -- - ----- = 5_.__ J ►t ------------------------------------------------------------------------------ Owner s Name----------- ------------------------------------------------- P o Address-_.------- ----------------------------------------------------- -- --- ------------------------------- -- Contractor's Name--- = : -------------------- ---------------------------- Phone �. �_/y_� i. t Installation will serve:-+Residence&]1_�--l-partmenf House ❑ Commercial ❑ Trailer-Court ❑ Motel ❑ Other ❑ Number of living units: ___ Number of bedrooms 1"_- Number of baths __S__-_ Lot size Water Supply: Public system mun'ity system'❑ Private ❑ 4Depth-fo Wafer Tableft. Character of soil to a-depth of 3 feet: ; Sand ❑ . Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No Ra�New Construction: Yes ®� ❑ ..FHA/VA: Yes ❑ No ®-' TYPE OF INSTALLATION[AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic T nk: Distance. from nearest well_____-__...__.___Distance from foundation__:_- ° '�t. .• W� No. of compartments_____:___ `. -------------Size--------------------- -• -------Liquid depth-------------------------`-Capac€ty--.------------------ Dsposal field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lof,line-_____--....____- ��f Number of fines-----------------------------------Length of each line----------------------- -----.Width of french--------------------------- Type of filfer maferial-------------------------Depth of filter material_-:--------------_-----Total' length---_-----------•-------------_-------•__-- Seepage Pit Distance to-nearesttwelf'l-W41, __'Distance from foundafion_l�% r A j � � � - �. DJ stance to nearest lot line__--------------- ----------- _ .._ ® Number of pits-:---5;-__.___:--`_ Lining material--a - - -----.Size: Diam�ter'__� - -�`-------Depth----` f1.-___-•--•---------_ F Cesspool: 'Distance from nearest well_____:_:_--__.-_Distance from foundation___________________ Lining material__.__.__-_:__-___- ❑ Size: Diamofer------a--�--- ----------- - ---------�-_Depth-----------------------�----------- --------- -----.-Liquid Capacity-- •----------------•--•--gals. \' Privy:' Distance from nearest well____--__.___._________________________________Distance from nearest building------.-_______-____._- 1•� ❑ Distance fo nearest lot-line--`- ------ ' _.---� •• _ i -- -- --�Q- ----------- Q ----------------- ---------------------------------------------- . _=-�Remodelnd or repairing (describe): � _ y --- ---- •------------------- ----- --- ----- - fill } -- - _--.--- --•------------------ -•---•----.. .-------•----------------- ---- -•--------------------------------------- --------.._..-----------------•- ----------------- ------:76 - t l I--------- ----------- 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. (Signed)_--- �'_ `-' -----------------------------------------------------------______ ______ (Owner and/or Contractor) By:--- Q_..'. 4 > l� -ti._- --------------------------------------------(Title)----- ' (Plot plan, showing size of lot, I ation'of system in relation to wells, buildings, etc., can be placed on reverse side FOR DEPARTMENT'USE ONLY APPLICATION ACCEPTED BY---------------------- ------------- --- - ---------- --------------------------------------------- DATE >� REVIEWED BY-------------=--------------------------- - - -- --- - ------------------------------------------ DATE--- BUILDING PERMIT ISSUED-------------------- • '-----------------_ _ - -- - -- ------------------------------------------- DATE_------------ -----�------------- •--•-----=�-------------------- -------- Alterations and/or recommendations----------------- -- -- ------ ,-------------------____--_ ti ------------ ---------- _ I l '�- . - ---------------I---- ----- -----------------•- --------- ---------------- -- --------------------- --------------------- -- ------------------------------------------------------ ----- ---------------------------- -----•------------------------------------------ r FINAL INSPECTION BY:.-= :_ = ------• Date -'z ---- ------- --- SAN JOAQUIN LOCAL H ALTH DISTRICT JJI i 1 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1-57 1=.KC0.