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FOR OFFICE USE: r A-------------------------------- '- Permit No. r------`--- "----- - APPLICATION FORYS�NITATION PERMIT ----~----------••--- ____ _ (Complete in Duplicate) Date Issued 1Q---- �_ __----- ---"_-_--- ._ 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 descr'ibed.y This application is made in compliance with County Or iinanc No. 549. JOB ADDRESS AND LOCATION-------------------------- _I.ITH_MA_N---- ------•---------------------- Owner's Name---------------------------- ----- R t- --- ------•--'- Phone. Ur � Address---------------- ----- kv------- -I- --• ----- ..2FG;1- ------------- --- ------ '� S Phone Contractor's Name--- ------ Installation will serve: Residence E] Apartment House Commercial ❑ Trailer Court El Motel [3 Other [I d k Lot size _-.. Number of living units: '9___ Number of bedrooms ._�-- Number of bath �/�---�--15-0--------�--- � r' Water Supply: Pub4ic-system Community system ❑ Private ❑ Depth to Water Table _._____ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ i date......:.............) No [��New Construction: Yes �o ❑ FHA/VA: Yes ❑ No ' Previous Application made: (if yes, �`. TYPE OF INSTALLATION AND SPECIFICATIONS: �(No septic flank-or cesspool_permitte&if-public-sewer:.is-available within-200_feet:) a(e5 Mated I f' ._ Septic T nk: Distance from nearest welll�U�1t,-`��--Distance from foundation__ i, No. of compartments------- --------- --Size-_..C*x.A�1U------Liquid depth-----'7 - -----------Capacity--1- ------ ' 0105 Distance to nearest lot line__�------------ Disposal geld: Distance from nearest well___ _ _________Distance from foundatio Number of lines--------- - Length of each line---'---• - ------ --Width of trench_-----' --------------'---------- Type of filter material ------Depth of filter material___!.-_-_--_-..___Total length__------:7_sr?__-_._____"---------------- f Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lotine__...._____.._.._ r ❑ Number of pits-------------- ------Lining material---------- ----------..Size: Diameter--------- -----'. ----Dept h....----------------------------- I Cesspool: Distance from nearest well Distance from foundation-----._.-_- ----Lining material-_.-.-..-------.---_.------.-._._____. ❑ Size: Diameter---- --- ----Depth----- -------------------------- - ----- d .-.------------------------Liquid Cap Dista e from neearesst 6 Capacity-.-. Privy: Distance from nearest well ._.___. "-"" " " ❑ Distance to nearest lot line------------------------------ --- ------- -------------------------------------------------- t Remodeling and/or repairing (describe :� �- 17� r ` �,� is ' ay_. 1� 'e-�' - ' - ----------- ----- - ' -------- ------------------------------------------------------------------------------------- --------------------------------------------------------------------- r ,v -------------------------------------------- --------- -----------------------------------------------------------------------------.---_--------------- --------------------- I hereby certify that I have prepared a plication and that the work will be done in accordance with San Joaquin County ordinances, State and rul and re u io of the San Joaquin Local Health District. 4 (Signed)_ �- -------------------------------------------------- - (Owner and/or Contract ,-� -- ------------- -------- - •— - (Plot plan howing size of lot, location of system in relation to wells; buildings, etc., can be,placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTE ___ _______ __ ____ _ --------------------- Y ------------------ DATE - - I REVIEWED B - DATE_ - BUILDING PERMIT ISS ED -------- - DATE-------- ------------------ -- ------------------------------ ---------------------- Alterations ----------------------------- ' ,' K --------------------------------------------------------------------------------------------- -------------------------------------------- -----------------------"-_-------- __..___.....___...__ Altera+ions and/or recommendations;__."_________________________ 6 - --------------------------------------I------------------------_- ----------- i — - Y--------------- ----------------' ---------- rr i ----------------------- ' '-----=----- - --- ' ' - - -------------------------- ------------- FINAL INSPEC N BY:....-' ------' Date /- ------�-=--�---------- --------------- S JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street i Stockton,CaliforniaLodi'California Manteca,California Tracy, California � _