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F R FFIC£"USE: _- ,. . - f ----------------------------------- . --------------------------- -- -�u d r� ` -- APPLICATION—FOi��SAN17A710N PERMIT Permit No. �--- ------------------------- -------- ------------------ ---------------- (Complete in Duplicate) --- ------- ---------- -_ T {Complete in Duplicafie) / (� Date Issued -._------�� --1�'-/ ------------------------ _------------- --------- This Permit Expires 1 Year From Date Issued Application is hereby made#o the San Joaquinl o`c alth District for a permit to construct and install the work herein described. This a lication is made in compliance itou y Ordinance No. 549. l �l 3—3! a -3�, .� .,r : �tS.$�- JOB ADDRESS AND 'LOCATIO -=--- ---- L- -�------------�'-��---------� !a �11I C- ------------------- -- Phone--------------------------------•---- E Owner's Names -ice' - --------- --------------------- ---------- ----- - -------------------------------------------------------------- Address------- ----------- -- ----------------------------- -------•------•-•--------------------•------•--------- Contractor's Name ----/J�7�II ---- -------------------------- Phone,_/;�--j9 Installation will serve: `Reside ce [�partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ • - ___ L-ot�size-" -- � i Number of living units: _=� Nuinber of�bedrooms -�_-`Number of baths ----��--------------------- Wafer -- ------------ Water Supply: Public;system ❑ Comms un ty.,system�❑ Private �epth to Water Table /, Fr-ft. Character of soil to a depth of 3 feet:J Sand [❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------- ---------- No New Construction: Yes No;❑ FHA/VA: Yes ❑ No 5? r TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance fII m nearest well "(, " Distant `rom foundation____ o---------Matf ria ----------- �'} No. of compartments-------��---------Size-- ---x- 1 --- ---Liquid depth--�------------------Capacity--- -cit Disposal field: Distance from nearest well -- _-._.Distance from foundation__ Distance to nearest lot line__.]__-_ �. Number of lines------ ---------Length of each line-A. /V ��_ �Nidth of trench___ _ �G - Depth of filter material-----/ Total length_____ l Type of filter material__ - - p r Seepage-Pit: Distance to nearest we4l_ __-?-._________-_--Distance from foundation--------------------Distance to nearest lot line----------------- ❑ `,, ... Number of, pits-----------------------Lining material-------------------- --Size: Diameter-----------------------Depth- - - --------------------------- A t I Cesspool: Distance from nearest well______________ Distance from foundation___.____----____-- Lining-material---------------------- Size:Size: Diameter----- - ------Depth----------------------------- ----------------------Liquid Capacity----------------------------gals. Distance from nearest buildin Privy: G e - Dktance,from nearest welt---�------?'------------------------------------ -------------------------------------------------•-------------------- Remodeling ----------------- " d rDistance to-nearest,�Iot line:'"----------------------------------------------•--------------------- i Remodeling anc/or repair g (describe):_ - I---- ------------------•-------------•-•--------••--------- --------------------------------------------------- -- y. -----------------------------------:. ------- : ---------------- ----•----------------------------- o , . 1 i ------------------ ------------ I hereby certifyt that have prepared tom' hi� s.application and that the work will be done in accordance with San Joaquin County ordinances, State s,+ n rules an gulations of the San Joaquin Local Health Distridt. - and/or Contractor) - --- ----- ---------------------------------------------------- -------- -------(Owner Y ( } -----.`---- (Plotp lot,, of system an relation to wells, buildings,.etc., can be p aced on reverse side). Ian, showing f � i FO R-,DEPA RTM ENT,.US E ONLY APPLICATION ACCE PTED BY =5 -------------------- DATE-----------�" 41---------------------- REVIEWED BY - _ 4 £ = - DATE------------------- BUILDING PERMIT ISSUED---- ---- "" ------------------------ DA"TE - Alterations and/or recommendations-------- ------------------------`- ------- ---_--------------•---------------------------------------------------------------------------- -------- - --------------- ------------------------ -------------------------------------- - ----------------- ------------------------------------------------------------- ----------------- , , ---.. -----------------------•- ---------- FINAL INSPECTION BY: -- --------- ----- Date � _.lv. . SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Flazeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REV19 Ed 8.59 3M 3•'63 F.P.0 O.