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�R OFFICE USE:, =Is%.T k-1iiS1TATIOK11ii%-RMIT ------------------------------------------------------........................... .---.--.- APPLICATION Permit No. ... .f � --------- ---- - -- --------------------- (Complete-in Duplicate) �- f - This Permit Expires 1 Year From Date Issued Date Issued --------- ...:-� � 2-- 047.- ?—c5 Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein desc bed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS A LOCATION_-01v i__L._.fi7- c c/f •,-- -_ r { Owner's Name t � --------------------- -- - - --------------------------------- - - Phone-Z/ ` "1.ka1------ Contractor's Name. G ------------ Phone. w -,�1 Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other XJ Number of living units: -./... Number of bedrooms -------- Number of baths-------- Lot size ----- __ -------- -------- ---------------_...--__-----. Water Supply: Public system ❑ Community system ❑ Privatejo Depth to Water Table _1,::i' ft Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ 4&6yA Loam ® Clay 1771Adobe ❑ Hardpan ❑- Previous Application Made: (If yes date............ _ __ I No New Construction: Yes ❑ No 2] FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: l (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ; Septic Tank: Distance from nearest well.................Distance from foundation........------------Material ----------_---..-_---- ..____.-...-..__,.... ... ❑ No. of compartments----- --- --------------Size--------- -------- -----------Liquid depth--------- ------- ------ Capacity ; Disposal Field: Distance from nearest well./00'.-----Distance from foundation.- `.........Distance to nearest lot line---6-r_..... ® Number of lines------_-2-----------------------Length of each line.. -4--0-----------------Width of trench 2_1!i . ----___-.------.- _.- ------Depth of filter material____ . 18-- ____ Type of filter material._�a _ _...Total length...._Lp........................ � Seepage Pit: Distance to nearest well......................Distance from foundation--------------------Distance to nearest lot line-.-.--------.._. ❑ Number of pits--------------.-_ -Lining material---------------------- Size: Diameter.----------------------Depth--------------------------------- Cesspool: Distance from nearest well ................Distance from foundation...............__ _.Lining materiaf-----_---------.______...-..-_._._- ❑ Sizer Diameter- -------------- ------------- -Depth--------------------------------- ----------------Liquid Capacity-.-------------------- -----gals. i Privy: Distance from nearest well ---------Distance from nearest building------------------..._......____.___--- ❑ Distance to nearest lot line -------------------------------------------..._---------------------------------------------------------------------------------------------- e90 - Rem -eling and/or repai in g (describeJ:__:. _ r -� -� -_Z-a-eC:. �---------- ------ ------�---- ---Wei-------------- }� "�` ... --------------- --------------- ------ ------------------------------------------------------ -------------------------------------------------------- --------------------------- ----------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State lawsd rules and regulations of the San Joaquin Local Health District. f - r D Si ned ... .--�" -- --- - ------- { g )- �z ( carter and/or Contract - O d/o or) By:.�, ?..��-- -o. -----------------------=----------------------------- ITiile) (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__ DATE = J = ------ REVIEWEDBY. ------------------------------------- ----------------------------------- - -------------------- DATE BUILDINGPERMIT ISSUED-------- -- ----- --------------------------- ----------------------------------- ----------------- DATE------------------------------------ Alterations and/or recommendations:---------- - ----- -------------------------- ----------- - ------------- -•------------------------------- -- --- ------------------------------- - ------------------------- ----------- ----------------------------- -- - --------- ------------------------------------------ -------------I------------- ------••-------------------------------------------------------------------- ------------------------- -------- ----------- ----------------------- ----------------------------•-------------------------- ----------•----------------------- 1 a ...................... --------------------------------- ------ -----------------------•-------------- -------------------------------------- ------------ ----------------------- --------------- , FINAL INSPECTION BY: - ....... -------------- Date---- ------- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haielton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi, California Manteca,California Tracy, California `w EA.9 2M 1-67 Vanguard Press r