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t FOR OFFICE USE: }---------------- ---------------------------•--- I ------- ' ------------ - ---------------------------- ------------ Application is hereby made to This application is made in con APPLICATION F R ' ITATION PERMIT Permit No... �.:':.- .......... (Complete in Duplic This Per_niit-Exlaires 1 Year From D Joaquin Local Health Distrlc+,for a perm nee with County Ord}ngnee No. 549, r JOB ADDRESS AND LOC ION-____ ____� �,{„____._ _---------_. _- Owner's Name ----Le f.J.._ - K,.,�------ ��.��` ..�i.1� �-----•--------- c ,�— .�'✓� j i ued Date Issued cons ruct an instal toe w6rk herein described. ---------------------------------------------------------------- -----.----•-------------------------------------------- .... Contractor's ....... �n-51Ls.ati ,esus!1,------ 0-ja ---------------------------------- Phone.h}U.b.:-:5 Q...4? Installation will serve: Residence ❑ Apartment House ❑ Commercial `1 Trailer Court ❑ Motel ❑ P Other IR cR> } ; $ P Number of living units: .------- Number of bedrooms -------- Number of�.__Z. Lot size,_..--_--_._---.____---------------------------------`__,._. Water Supply:_ �ublic system ❑ Community system ❑ Private & Depth to Wafter Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Laamr❑ ',Clay;Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes, date -------------------- ) No E, New Construction: Yes® No ❑ FHA/VA: Yes ❑ No ❑ TYPE -OFANSTALLATION AND-SPECIFICATIONS:—;---- (No SPECIFICATIONS:-- �- ---------•-- ----- "� �` (No septic tank or cesspool permitted if public sewer, is available within 200 --feet.}= E ,-1 T • Sa tic Tank: _ _ .Distance. from-nearest-well_:�D,-_+.. Distarc-v rom fpundltion�l-_Q :_.... Mat riai:: i* _C A ::...�, vtiC� E p t i t. i x -b „x .Id .. tri ' 1 i- 1, t5 El 02-) No: ofscompartmentsL---_---7 '------Size_2.-- !-x -d,;:.Liquid depth_Z,------ '.-.--.--.--_Capacity r ---.-&0.d. Disposal Field: Distance from nearer well.. p'_i _ Distance from foungatio�_-�Q�ti_`7Distance to nearest lot Cline.. ... -„-........ Number of lines: -kA -..i_______________________ Length of each line2 t____t.-_7 �_________. idth of trench...... .____.____._____•----_-. g __ �: 17 � Type of filter materials {� �_C-xa kDepth of filter material_.._:�$_L.______._.Total lengthza--__�5-e....................... Seepage Pit: Distance to nearest well ------------------- --- Distance from•,foundation____._,:.-::.:-_ Distance to nearest lot line.. ...... .______-- ❑ Number of pits ----------------------Lining material --------.-.------------Size: Diameter----,------- ......... Depth_ ---.-.-------------.-,.--------- a j cG iji 7V1 f,�: r13 fel I Cesspool: Distance from nearest well ------------- _- Distance from fouuncia+tion-------------------- .Lmmg materia ----------- ..._._._________.____.---- Size: Diameter.--- ------------=------------ Depth- -=-=--------------------------------;- Liquid Capacity- -------------------------- gals. Privy: Distance from nearest Well ..... -------------G_-:`- �_ ��_Di`stance from mearest=5uilding_______________.-.---------,_._._______--- ❑ Distance to nearest lot line'':__` _. _ } i_' __---__.-;----i____- :-=_'_--____- --•----- . . Remodeling and/or repairing (describe)------------------` == ----------------Q -_-_«-'-"--,------------.,..: ---- — __--�—: --------------= r _ ".---''.-------•-----------------• ----------------------------------- -......... ------------------------------------------------------ .....-- ---------------------------------------------------------- ••------ -..-------------------------------------------- ------ --------••-•----------------------------._.---------.-,---••---•--------•--•-------------------- 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 Swann Joaquin Local Health District. �j� c��f/ f'✓� (S C�-->-------------------------------------------------------------------(Owner and/or Contractor] {Signed}-----��••.---- : - - - -----.:.----------------- �_ /,l�n�Title------------------------------------------------ - ------------ Br------------------------------------------------ { } (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- a ltd¢ ?moi ` 1Y -o ------------------------------- DATE -----`1 .-.}a ...- REVIEWEDBY ------------------------------------------- ------------------------------------------------------------------------•-----•- DATE ------------------------------------------------------------ BUILDINGPERMIT ISSUED ------------------------- ------------------------------------- --------------------------------------- DATE ------------------------------------------------------------- Alterations and/or recommendations: --------------------------------------------------------- -------------------------------------------------------- ................................. w -------•---•--•----•--------------------------------------------------------------------------------------•-------------------•----------•-.........---------•-----•---•-------•-•---•--------•-----•------•--•-----------_.. -•-----------------------------------------------------------------------------------------------------------------------------------•-•------------------------------------------------------------------------- FINALINSPECTION BY------------------------------------------------------------ -- Date ------------------------------ ------------------- --------------------•-------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 west oak Srreet 124 Sycamore Street 205 West 9Th Street Stockton, California Lodi, California Manteca, California Tracy, California ES 9 REVISED 8.69 EM 5-51 ArLAS F -