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FOR OFFICE USE: ------------------------------------------------ ---- --- ----------------- ------ .... --B_______________lv---___..... APPLICATION FOR"'ATIITAT:ION PERMIT Permit No. --------- --------------------------- --- ---` -- -- (Compleie`in Duplicate) Date-Issued ------------ ----_------------ This Permit Expires'l Year From 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&h�,unty Ordinance .No. 549. JOB ADDRESS AND LOCATION---C1�4-e a-D!..E-----419-.--- —(.1-if-----Ld-T--------SQu T� ------ r Owner's Name ----------------------------------------------- ----- ------------------------------------- Phone------------------------------------ l Address 9 y yC_ -.t.e ' .... . 5- Contractor's Name---------- -•--•---- Phone.-- -`-G.-"- .. . eel___ ' �,ct�r-' ---_-_-- 3 1�.4--2----- r Installation will serve: Residence 'k Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel E] Other ❑ ._ Number of baths .2___ Lot size ___`]'_ . t A.._�,�_' _____-. Number of living units. -1---- Number of bedrooms _� .�_____... __.._______ Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table 40_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe R` Hardpan ❑ Previous Application Made: {1f yes,date......--------..----] No�Z New Construction: Yes)4 No ❑ FHA/VA: Yes ❑ No x TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest welt___. 1- .t ____-Distance from foundation-___ _0.._._._. Material-------��r� ------------ NNo. of compartments----------I----- -----Size---St X, A--°I--- -----•Liquid depth-----V-4z_-------------Capacity---t-:L.Q_Q.._V Q Disposal Field: Distance from nearest well_-_,570........Distance from foundation-_-.__0.'_._.._.Distance to nearest lot line_--_S-,_f_----- . 19 Number of lines-__________Z__`-----------------Length of each line---------7S_'___---------Width of french-------.7-54--_-__-_---_-___- ' Type of filter material__J,_ADC,&._Depth of filter material---------fc? !-_-__Total length----------------------/.5-O P---------- - ((�] y t r Seepage Pit: Distance to nearest well-._#�Q .-____Distance from foundation --------Distance to nearest lot line----- _,_______ —0 Number of pits------I-------------Lining materiai_,S_r-_1 _0e_X_Size: Diameter._.____`--------Dept h-------as ---------------- 6- Cesspool: Distance from nearest well------------ from foundation--------------------Lining material-------------------------------------- ❑ Size: Diameter----------------- - - ---- --- -------Depth.------------ -r------------- ------ ------------- Liquid Capacity----------------------------gals. Privy: Distance from nearest weft_______________________________--:--------------Distance from nearest building----__-_...--.-_-..__-_______.._____.__._. r ❑ Distance to nearest lot line--------- ------------------ --- - -------- - ---------------------------------------------------------------------------------------------- 0,. ., Remo eling end/or re ai in (describe}:._ ___-_ c�. �_-___3__ �. . ' ------ -------�---�-----------------------••------------------------- ---------------------------------------------------- ----------------------------------------------------------- �} -----------------------------------------------------_---------------------------------•--------------------------------------------------------------------------------- --------------------------------------------------- V I ----------------------- ---•------- ------------- --------------------------------------------------------•-------------•----------------------------------------- ----• ---------------------------------------------- I hereby`cerfify that I 'have prepared this application aril that°thwork will be done in accordance with San Joaquin County F ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. �------:+5 ______ ____________ Owner and/or Contractor (Signed)--------- -- -- --------- ----- { ) By:-----------= - - --------- -- -- (Title)------ -------------- ----------------- ---- -- ------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY :. APPLICATION ACCEPTED BY DATE festa------------------ REVIEWED -----------REVIEWED BY--------------------------------------------- -------------------------------------------------------------------------------- DATE------------------------------------------------------------ 1 BUILDING PERMIT ISSUED----------------------- ------------------------_ -- =- ------------------------------------------ ----------------------------------------- ---- DATE.-----------------------------------------------•------------- Alterations and/or recommendations-------- -� {//- ---- / ---------------------------------------------------------••---------- ------------- ----------------------------- - } --------- --------------- ------------ -------•----- ------------------ ------- ------------------- --------- ------------------- ----------- .�z. ---------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------•---------- ----------------------------- F ----• -•---- -- -------- ------ ---------- --- --------- FINAL INSPECTION BY:.- ------------------------------- / 1p . - - Date- `_ --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO. - ..