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FOR OFFICE USE: T ----------------------------------------7777-- --7777-- _______________________________ _______---- -------------- 777__ APPLICATION FOR``S5kMTATION PERMIT Permit No. -------------------- (Complete in Duplicate) 1�1 - -- 7777-- -- " 1 Date Issued _---__--___---------------_-_____._._-- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in complian e with County Ordinance No. 549. Mtn JOB ADDRESS AND LO TI N-- _RA ------ ��r/ ' l ilk T ----A-Vt----_-------------------7777-------7777-------- Owner's Name----------P �C'----------�� ©> F'------------- �YIMTI=RSQ4Phone Address-------------------_--�T ---------C ox........ 6-1------------j--------------------------------------_____-----------------------------------------------------7777-- Contractor's Name----- _ ____-______ Phone____________________________ ---------------------------------------------------------------------------------------7777-- -7777-- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer mart— Motel ❑ Other ❑ Number of living units: --1----- Number of bedroom>�_ Number of baths _-(----- Lot size __Ac-9Eo4G.�____________________________ Water Supply: Public system ❑ Community system ❑ Private iR"5epth to Water Table ba_ ft. Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date.-------- ----------) No © New Construction: Yes ❑ No FHA/VA: Yes ❑ No RT' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----- -__Distance from foundation---1Q---------M'aat'erir-al__ ED{ ©O ______________ 0� No. of compartments__-__Z____-_-_-Size__ _X -X Li uid de .th__ ---_____Capacity... a A t Disposal Field: Distance from nearest well- Distance from qfoundation...-l0--------Distance to nearest lot liner_,.___-_.__. C E� Number of lines----------/---------------------Length of each line------�QQ� -_--�.. _ ,e� �, _---_.Width of trench___ _- f __-___________ Type of filter material--- --__Depth of filter material___-__E-/--__-------Total length________,�_pL?_______________________ 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----------------- from foundation.-------- ----------Lini_pg material----------------_--------____________. ❑ Size: Diameter------------------ -------------------Depth----------------------------------- ---------------Liquid Capacity-_------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------__---_-___-_---___--_---_------ p ❑ Distance to nearest lot line------. ------Y,,-4b-;-------- ---------- .4_�4 MOV- OFF— ~ Remodeling and/or-- repairin (describe -_ p 1 _ Rr�J_�_ -. -____..-5 � -- -----------------T-0---------� - -----------�' ----- - -- '---- - ----1 � - -----)-..... -----------�'`-�-f-�-�------1��--------N��-�------Td--------R�-�---�E'V_�_.__ _.14_nP_QTttt�R�TR�3�_�_��.---lS----P�4RKr�A - - - Q IX T------- - > 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)-- - --- - -------------------- ------------------------------------------------------------------------(Owner and/or Contractor) ---7777-- - By--- --------------- --+--------------------------------------------------------------------(Title)----------- --------------------------- ---- --------- (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--- -� _C��--------------------------------------------------------------------- DATE---- '/ —------------------ REVIEWEDBY-------------------------------------------- ----- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED - ISSUED-------------------- �------------------------�---�--------------------`�-- -, DATE--------------------------------------- -------------------- --------------- -------- ' 77-- 7777 . ..........................and/or recommendations:-_-_ ------------------------ ----------------------------------7777- .e-------.:4�� - ------------------------------- ---------------------------------------------------------- ------------------------------------------ ------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY------------------------------------------ ----------- --- --------- Date- ------ ------------------------------------------------------------------ - - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California