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Z. APPLICATION FOR 'iA Permit No. jCanslten Du licai }�FZRES ONE YEAR f;�',J p / { Date Issued __�_{T(_1 -- E'ROM'DATE Application is hereby made to the San Joaquin Local Health District f r a perms o construct and install the work herein(described. This application is made in compliance with County Ordinance No. 549. it JOB ADDRESS AND LOCAT O(V--______ _--�--�_-_--. _,- '` __--------- i Owner's Name ------------lh.!-�AJ L ----1 -- ------------------- ---------------------- ---------- Phone-hLo----2-VI? n i �I Address---------------------------------�1.1 �? ---` Contractor's Name--------------441- .— �. �--; Phone ff--------------- � IP Installation will serve: Residence E] Apartment House ❑ Commercial Trailer Court p Motel ❑ Other ❑ Number of living units: __1___ Number of bedrooms -------- Number of baths ----- size ----------------------------------- Wafer _.____________________Water Supply: Public system,i?�Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of'3 feet: Sand El Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe L&,-m�rdpan ❑ { Previous Application Made: Yes o New Construction: Yes [Er"'No ❑ FHA/VA: Yes ❑ ' .No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r r� p (No septic tank or'cesspool permitted if public sewer is available within 200 feet.), { /q Septic Tank: Distance from nearest well�_y_it-—Distance from foundation-,/-Q__________.Material___---�-1�___ _---- --------------- No. ------------ No. of compartments-.----' -----------Size___9A_5* ___Liquid depth------- --------________Capac _f_ Disposal Field: Distance from nearest well)'Lt�_Distance from foundation_1Q. -------Distance to nearest lot-line'--- e Number of lines__--_/______�___j_�_,____________Length of ach line-x _ a� __ _` oftitrencLN h.� Type of filter material_ �!( _-__-_____Depth of filter material___.___--p-----Total leny,r_ ____= "" .. Distance to nearest wefl__�)--f�'1-„___Distance` f_ro}, foundation___�_a____,_____.Distance to near est lot Ime�- :__ Number of pits__j----_____----_Lining material__ C�J�jI -_____--.Size: Diamete,r__�V_1C01d_.Deptn_-_ �-- ---------- P -well from .foundation--=-----------------Lining material--------------------I�--------------- p --------------- Cesspool: Distance Diameter nearest well____ - . Depth --------------------------- -----------Liquid Capacity------------------ ii--------gals, Privy: Distance from nearest weft____ -- El ------------------------------ from nearest building____-_____________- ----I ------------- --- ---------- --to nearest lot ling ------------- -- ------------------------------------- ----------------------- 4 Remodeling and/or repairing (describe)------------- -----------•-----------__-----------------_------ _ ------------ --------------------------•------------------------ ---------------- S --------------------------------------------:---------------------------------------•-••-•--------•---------------•------------------------------------------------------ ------------------------------------------------- ll' [ . ------------------------------------------------------------ r F pp -'--------------------------------------------------------•-------------- ----------------------------------------- ------- --- -------h- ------------- --- --------- ---------------------------------------------------•--------------------------------------------•------------------ -------------------------------- ------------- --•-------------------- 1-------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St t laws, and rules and regulations of the San Joaquin Local Health:District. (Signed) --&/-��_-'' ------------------------------------------ ----------- ------(Owner and/or Contractor)ti IBy:----_------------------_------------••------------------------------------------------------------------ .----(Title) J6 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side), II FOR D ARTMENT USE ONLY (III APPLICATION ACCEPTED BY--- - -------- --- -- ------------------------------------------------------- DATE------- REVIEWEDBY------------ -------------------- --------------------------------------------------------- ---------------------------------- DATE BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------- ----------------- 'DATE --------------- Alterati�ns anor recommendations: --------------- fi�” - ------ -= . ------------ - t-7 FI�AlNSPECTION BY:. ---- - Date ------------ ----- �7�/ SAN JO QUIN LOCAL HEALTH DISTRICT j 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Revised 1.57 F.P.CO• '�'� •�� 19�s �I