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FOR OFFICE USE: APPLICATION FOR fn�A41TATION..*PERMIT Permit No. _I�A* -------------------------------------------------------- (Complete in Duplicate) ----- -------------------- --------- --- -------------- Date Issued -----------------------------------------i-;--------- This Permit Expires I Year From Date Issued 11-6 tqz/- e2 L(3--0/ Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein descried. This application is made in compliance with County Ordinance-N o. 549. JOB ADDRESS AND L CATION. --------- ------------------------------ ---------------- ------- ---------- ------- Owner's Name-------- --------------------------------- Phone------------------------------- --------------- Address--------------- ----------------- -------------- --------------------- --------------------------_----------------------------------------------- Contractor's Name----- ------------------------------------ ---------------------------------------*--------------------------------- Phone--------------------- Apartment House [-] Commercial [] Trailer Court E] Motel E] Other E] Installation will serve: Residence Number of living units: I------ Number of bedrooms �___ Number of baths Lot size ------------------------------- Water Supply: Public system C] Qom' munity system E] Private 00 Depth to Wafer Table ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay LoamU Clay E] Adobe E] Hardpa'nZ 0 Previous Application Made. (If yes,date--------------------) No W -New Construction: Yes j�o No E] FHA/VA: Yes 0 No ❑ i i TYMOF INSTALLATION AND SPECIFICATIONS: 7 (No septic tank or cesspool P;rmiffed if public sewer is available within 200 feet.) Ir Septic Tank: DistancJfrom nearest ------Distancp from foundation----- depth ------- - - Material --------------------- No. of comparfr�er�fs_-_-_;�------------------Size- -----------Liquid ------ Capacify_/.7-_&--0_�------- Y--------------- Disposal Field: Distance from nearest weil_ro-------Distance from foundation---Zq---------Distance' to nearest lot line___ _'_____. Number of lines!,-2— ------Width of trench-. -----------:-------- 7 - .- - Length of each line__. ----- -------------- ------ ,..,..Type of filter m *4 W__Depfh of filfer'maferial----/f-----------Total Iengfh__1_*7__-__--6__1----------------- ------- i Seepage Pit: Distance to nearest-well---/A�7R--------Distance from foundafion-,/V- rest lot line--.,�_E....... -:---- ----------------J)istance to nearest Number of pits--"----- -------Li�inig materi -------Size: Diameter--- Depfh__.1A-r`-------- . Cesspool: Distance from nearest well____--_----_--Distance from foundation.-------------------Lining material------------------------------ ------- 1 El Size: Diameter----------------:--- - ---- ---Depth-------------------------- --- ------- -------------40 Liquid Capacity ------4 ga)s. Privy: Disfance.fronn nearest well-------------:------------------------------------Disfance.from nearest building_------------.__--_--_____---_-!'_._-._ iV ❑ Distance to nearest lot line- - -7------------------ --- - --- ---- - ---------------------------------------I------------------------------------------------------- Remodeling and/or repairing (describe):----------------------:--------------------------------------------------------------------------- ---------- --------------------------------I- ----------------------------- --------------------------------------------- ----------------------------------------------------------------- ----------------------------;r------- k . -----------------------------------1 4 ---------------:_ 11--- - -- -------------------------------------------------------------------------------------------I--------1.____1---_11......... .......---------------I---------I---------------------------------------------- ----------------------- ----------- ------- --------- ------------------------------------------------------------:------------------------------------------------------------------------------------------- ------- 1 hereby certify fha+ I have prepared this application and that the work will be done in accordance with San Joaquin County 1 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed,--------- ------------- - - ------ ----- ------ ---------------------(Owner and/or Contr for By%------------- ----------------------- ----------------------------------------------------------------------------------------ffif`16)-------------------- -------------------------------- (Plot plan, showing size of lot, location of system in relation-to wells, buildings, etc., can be placed on reverse side). Il I I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B DATE----- -------------------r------------------------------------- ---------------- --------------------------------- REVIEWEDBY--- ------------------------------------ ------------- ----------- -------------------�------------------------------------- DATE----------------------------------------------------1p BUILDING PERMIT,ISSUED------------ ---------------- DATE---------_--------------------------------------- !� ------------------------------------------------------------------------- --------- Alterations and/or recommendations.--------------------------------------- ecommendations:------- ------------------------------------------------------------------------------------------------------------------------------------------------i!------- --------- ----------------------- ---------- ---------------------:------------------------------- ------------------------------•--•------ •-------- -------------------P --------------•--------•-------•------- ------=-•----------- r------------------------------------------------------------------------------------- ------t---------------------- ------- --------- -------- ----------------- -- ------------------------------------------------------------- -------------------------------------------__------ ------- ------------ ------------ ---------------- ----- ------- -----------------------------------------------7-------------------- -------------- ----------------------------------- ------------------------------------------------------------------ ---- ------ -------------- FINAL INSPECTION BY:,:iu ..�_ ------------------------------- ----------------------------------------- ------- ---- ----- --- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Mazatlan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California FS 9 REVISED 13-59 3M 3-63 F.F.C Q.