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APPLICATION FOR �-.d,41TATION PERMIT Permit No. z--- (Complete in Duplicate) Date Issued ZU �ic Application is here�y;made to f or t. �_J"clui�L�6: 1 Health Di trict a perm to consftuct and inst�e W,erein described. Thi�,app ica ion ill in compliance with Count 0 rdinanqe o, 549, 1�.JOB ADDRESS AND LOCATION -- ------ -- ---------- 0. ........ .0__� Nam -IV Owner's N k I%ct. - - - -- ------ ---- -------------------------------------- ---- --------------------------------------- Phone--f ------ ------------------ - ------------- ------------ CAL Address rs,(- --------- . .................................................. - ----------------- --------------------------- --------------- + Contractor's Name--•--------0i -L-, -A...... C--------------------- - --- --------------------------------- ------------------------.--. Phone.1--0 7. i.. y I Installation will serve: Residence [v-'-'Apartment House E Commercial E] Trailer Court E] Motel E] Other.F1 Number of living units: Number of bedrooms ----12 Number of baths __.-L_ Lot size ------4-0----K j E] - -------------------------- Water Supply: Public system Community system El Private Depth to Wafer Table _,Wft. Character of soil to a depth of 3 feet: SandE] G�A. ravel Ej Sandy Loam. El Clay Loam El Clay Lj Adobe Hardpan E] Previous Application Made: Yes E] No �Kl\le_w Construction- Yes D�No E] FHA/VA: Yes [] No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic.T k Distance frorninearesi well-----------------Distance from four�da_fion--------------------Material----------------------------------------- ------ p n-,- - - . - j - - 114 No. -6iTF -Capacity----------------------- of c --- -- ---Size----------------------1--------Liquid ------------- --------- Disposal Field: Distance from nearest well..._......_L-Disfance from foundation--------------------Distance to nearest lot line--------__---- . Number of lines__{_____________I-------------------------!----.-Length of each kn'e----------------------------- Width of trench----------------------------------- Type of filter {Iter-material-----------------------Total.length.'-_-_-----_------_------_-__.--_._-_---- Seepage Pit: Distance to nearest qn e 0 �sf we�f --Distance from c t nearest lot -\�---4.-OP, Number of p;fs----A_-------- [fining material----- -_--.Size: Diarreter_---_;F,;,0"Dep I 'I h Cesspool: Distancefromnearest well---,:-------------Disfance from foundation--------------------Lining material__-. --------------------- ❑ Size: Diameter------------------ -- - -----Depth----------------------------------------------------Liquid Capacity -------------gals. �Drivy: Distance. from nearest well--------- i ---------------------------------------1-Distance from nearest building_�--------------------------------------- `-------------------- I r I ❑ Distance �o nearest lot line ------ ------------------------------------------------------------------------ Remodel - ------- ------ ----- ------ - --- and/or repairing (describe)-------- -------------- --- ------------- --------------------------------------------I------------- ---------------------------------------------------------------------------------------------------- ------------ -------------I------- ---------------------------------------- ------------------------------------------------------ -------------------------------------------1----------- ---- -----------------------------•--------------------------=----•---------------------------------------------•---------------------------------------------------------------e---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)-_ -------- -------- --------------- ---------------------------------------------------------------------------------------- ------------------- 7..--'--_-.-(Owner and/or Contractor) By--------------- -- .......... -------------------------- --------------------------------------------- - ------------------------- p (Plot plan, showing size o Ioi, location of system in relation to wells, buildings, etc., can be placed on reversetdia). size FOR'DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- 1 DATr--------------------------------- - ------------------------------------- REVIEWED BY--------------- --------- - BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----- -- Alterations ATE------ Alterations and/or recommendations---------------------------------- ---------------- ....... ----------�Z'ZX. _^,004.44W -L-----------9... .L", to " 44�vl --------------------------- ------------------------------------------------ -------•-.. ...... ......; ------------------- -----------------/--------------- I I'll, ----------- --------------I-------- -- - ----------------------------------------A----------—---------------------------------------------- ------------------ ---------- ----------------------------- .e A -�_ Ce4z_J14 1�4Ktn------ ----en 6� ---- ------ ------- ------------- --------------------------------------- ----------- ------ ---- --------------------------------------------------------------------------------------------- 01- 0 FINAL INSPECTION BY:. ----------- - -------------------------- ------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Sou+h Xrriarican Sfres+ 300.Was+ Oak S+reef, x,132 Sycamore Sfree+ 814 North "C" Street Stockton, California Lodi, California Manteca, California 4 Tracy, California W, ES---9-2M Revised 1.57 F.PCO.