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F R 0-410E USE: t� I ----------- -------------------------------------------- APPLICATION Ft�R 5A NITATION PERMIT Permit No. _Z'1.1.. ... ...... -- ----------------•- -- (Complete in Duplicate) -. ___ -- This Permit Expires 1 Year From Date Issued Date Issued ------ 4 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 compliance with County Ordinance No. 549. JOBADDRESS AND LOCATION------- .: . .......... 1!---------------------•----•-------------------------------------•--------- Owner's Name----------f4 .. -11? - -- 7' -----.. '? LYTC� --• -------------"`=------------------•-----------------••----------- Phon3�-.�.4'`�. Address-----.=......................-:rl'mwlg�----------------- -------------------------•-----••s---------•------------= -------••-------------?-----.`----------------•---•-------.'_--- Contractor s Name. • '��_�._ .,� IS'�Y.rt` Q/✓J` -----/N -,-_---------------- --------------- Phone.//494�?6±�.� Installa#ion will-serve: Residence &K ApartmentiHouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ I Number of living units: __*__. Number of bedrooms _n. Number of baths __/---- Lot size ____.f,�__.-- -----••---••• "t.- . _�- .. - Water Supply: Public system ❑ Community system ❑ Private I2 Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 1® Hardpan ❑ Previous Application Made: {If yes,date____________________) No fie' New.Construction: Yes ® No ❑ FHA At Yes ❑ No 11 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 foundatian__._�±G'�________.Material____ _['r___ �!�'�'r.............. + _of --Liquid depthCapacity---- ® No. of compartments_.--•-- ------------•-Size_--- ------.••"---- Disposal Field: ,..L Distance from nearest well___ Distance from foundation....!<'..........Distance to nearest lot line_._.,:........ Number of lines-------------f-------------------Length of each line..------ ..............Width of trench-------. !f -.......-------. ® ' Type of filter material.... Depth of filter mate rial----/�h_--_-_._Total length.............� -.._.________........ I ' Seepage Pit:. Distance to nearest,well_-_/�__t_______Dlstance from foundation_....�?j........Distance to nearest lot line..... ® Number of pits_______)..--_______Lining material___,1`�L �K___.S ize: Diameter.-._.. _.�..____.Depth___- --- �3'---- ...... Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-------------._.____-•----------____- ❑ F. Sixe': Diameter-------------------------------------Depth.---------------- I ---------------------------Liquid Capacity-------------•----------- gals. Privy: Distance from nearest well------------------------------•----------------._Dstance from nearest�building_____._._________.•.-.-•.---- •...---'-- _.; 0 s Distance to nearest lot line___________________________. _ ----------- ------------------------- - ---•---- ---- Remodeling and/or repairing (describe):--------IA-IX7W�&Z-------- j --------' ------•-----------------------------------------............. �_ ---------------------------------------------------------------------- ------------------------------------=----------------------------------------------------------------- -------------•........ ------------------ -------- s ---•-••---- •--•-------- -----------•------------------------------•-- •--,....---------- f '--------------------------------1 t _ _ _________ __ # hereby cert-#y that I have prepared this"----•----------------------------••----------------------...-----------------•--•-----••------------ application and that the work will be done in accordance with San Joaquin County ordinances, tate laws, and rules and regulations of the San Joaquin Local Health District. . 470 a __ ___ _ _____(Owner and/or Contractor) (Signed)------•-•- =��• .P /Sid' S�iRcjJ' iY°' _________ r : •G :_.. ----------------------------------(Title)...... ---------------_ ---------------- (Plot plan, showing"size of lot, location o system in relation to wells, buildings, etc., can be placed on reverse side). ' x # FOR DEPARTMEW USE ONLY APPLICATION ACCEPTED BY_ - -------------- DATE..-_-/ f d `•_�_.�-------------- REVIEWEDBY------t------------------------------------------------------------•--•------ --------- ------------------ ------------------ DATE-----••--------•------------------------•--••- BUILDINGPERMIT ISSUED--------------------------------------------....---------------------------------------------------- DATE.. . `r----------------- �'. Alterations and/or recommendations:-------( �-.�- ----•-•-•----------------------------•-•--•-----------•-•--------•--------------••-------•----------••-----------------------....--------------------...------------------------•-------•---- i ._.--------- -------- -------------------------------------------- -•------ -----•--------------------- •-------------------••- -----------------•---•-----------•----•----------------------••---•----------------- . FINALINSPECTION" BY:... _.. ... - ---•---------- ---------------------------- Date ' � --- ._....... (.... --------------------- SAN ----. _ ._._..-----SAN JOAQUIN{LOCAL HEALTH DISTRICT k 130 South American Street 300 west Oak Street 124 Sycamore Street 205 West 9th Street t Stockton,California Lodi,California Manteca,California Tracy,California E8 9 REVISED S-S9 9M 5-61 ATLAS } i +#