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APPLICATION FOR ,NITATION PERMIT Permit No. .-f (Complete in Duplicate) // This Permit'Expires I Year From Date Issued 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 compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION----------41-1 AQuth--Burkett_ Owner's Name------------------('-••---�-,----�,£lf� &b@�-_ CI•usW1'OTrd ---------•----------------------------------------••--------------------------- -' M Phone.:H�__ 2— 009 Address,,-------------- - -------------- ---- �' ••----.•------------ 1 . QuthBurkett--- - -------- Contractor's Name----------Dei- `�eptiC. Tank Sex"Vi-Oe ---------------•-------- Inc:------- •---------- - xo• 3-�z269 - -•------ Phone---•-....---•--- -•- ---•------•Installation -- will serve: Residence KI Apartment House ❑ Commercial � ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _j--_ Number of bedrooms ------ Number of baths __- -- Lot size ------�5-------- - ------------------------------------------- x 102 �. - - Water Supply: Public system [ Community system El Private E] Depth to Water Table _- s- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ® Hardpan ❑ Previous Application Made: Yes ❑ No ® New Construction: Yes:U No ❑ FHA/VA: Yes ❑ Nom) 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-------------------Material--_--_-----__- -__-- --.-_ Existing No. of compartments_...------------ ---------------- Size_. Liquid depth --------------------Capacity-------------- -------- Disposal Field: Distance from nearest well.---- --,Distance from foundation----eeQ.. ----.. istance to nearest lot line-----�_--__-- Number of lines------------ ------------ Length of each line__-- ' 1 g —Width of trench----- Type of filter material---- - - Depth of filter material------ -----Total length--- ---�-----1, ----- Seepage Pit: Distance to nearest well---n0-------------Distance from foundation---__ ------.Distance to nearest lot line------5' ----- ,} EX Number of pits---------2_--------Lining material-----r9-4 Size: Diameter---_--3 t1-_-_----Depth--2 t ------------------- Lining material----------------- ---- ❑ Size: Diameter--------------------------------------Depth--------------------------- .-Liquid Capacity gals. i,i qp t'- --------•---------------- �. Privy: Distance from nearest well----------------------____--_ ---------------_.-Distance from nearest building--------------------------------------El Distance to nearest lot line---------------------------_---- ------------------------------------------------------------------- -- Remodeling and/or repairing (describe):-__--_--_adding'---!!"rnaf d--- Q0;_ 101.4g sy8 em ---------------------------------•-----•-•--------------------------------------------------•---------•----------------•------------------------------------------------------------------------ ---- - 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)-------- De�,t 5c----Tank , _ -------------------------------------------------------------- .andor By:-----Pery---0.----Wrthan - Contractor)'_ (rifle) G�T , Ngr« (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FO DEPART ENT USEONLYAPPLICATION ACCEPTED BY- ---- -------- - --------- - ------------ - REVIEWED By ------------ DATE- - ---------------- ------------------------------------------------------------ -------------------------------------PERMIT ISSUED -----------•---------------------- ------------------------------------------------------------------ --- DATE---------------------------------and/or recommendations:.__----._-------------- - --- --------------------------- ------------ -------- -------- ------ ��__ ------ --------- ."' - •� --------------------------------------- --- - --------- ---------- --------------------------------- +/,.-'� ----------------- FINAL INSPECTION BY:.- -- -- - --- ------ ----- Date---- ------------- 2�--,� ---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C" Strew} Lode, California Manteca, California Tracy, California FS-9-2M Revised 8-'59 F.RrCD.