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Al 1. y, APPLICATION FOR41NITATION PERMIT Permit No. ............... (Complete in Duplicate) Date Issued pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. ,jWis application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LO TION----------- ��'. . -- --- ------ -------• -------- ........................... ..... ------ Owner's Na -� - -- -�•--•-•. Phon , Addres . ..... ------- - --------•--- Contractor's Name d--- ----•--•• -----------•-------------- .•. -------- -..-:--- Phon ___. ..... ......... Installation will serve: Residenc"eA�artment Houseo imercial F❑ Trailer Court ❑ Motel Other F]Number of living units: __�.__ Number of bedroom s ./:-,umber of baths .._ Lot size _` 11Q?h/_al/_.................. Water Supply: Public system Co punity system Private ❑ Depth to Water Table Character of soil to a depth of 3 -re f:: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe, ' Hardpan ❑ Previous Application Made: Yes ❑, NoNew Construction: Yes No E] FHA/VA:Yes [:] 'No� - TYPE'OF INSTALLATION AND %I91'CATIONS: (No septic tank er'cesspooi#ed if public sewer is available within 200 feet.) Se tic Tank: Distance from ngarest wefl, d' Distance from foundation---undation___ � .__:Mateyal �._. No. of compartments -----------------:_Size___/___, ... Liquid depth--_y1',�'---------------Capacity--.. .... -- isposal Field: Distance from nearest we _Distance from foundation__�� Distance to nearest lot line ^ Number �f lines---------/ -Length of each line_________ Q_7 Width of trench - _ Type of filter material -- ----- Depth of filter material____ ___.;_Total length______ _________ _Q__,�_____.__.- Seepage Pit: Distance to nearest well�,c _ -Distance from `ndation_lel �_ ..Distance to near Number of pits_- —__.:__ Lining materia -_ _ ------Size: Diameter .� .._....__De m' edesspool: Distance from nea7f well ._ Di ance from foundation______ Lining material_. ._.____ I ,, ,w..._, ize: Diameters---r-------------------------- De�----- ------- ----------- - ----•--------_Liquid Capacity . -•- ---- •--•-gals. 1 Privy: pistance from nearest well _. _ - _ _ _ Distance from nearest building t istance to nearest lot line -•- ------ ---•- --- ------ _--- ------- •------- Remodel /or re _a ring (describe):_ % „ ......4e.,...... �- - 4--•--------•-------•--.-•----•----•----------•- I hereby certify thatY have prepared this application and that theworkwij be done.in..aecesdance<..with.Stn Joaquin County ordinances, Sfia laws,. es and r ions of the San Joaquin Local Health District. (Signed)------ / �' - ' (Ow rand/or Contractor) By: s ---.• ------------------------------------------------ --- -=-1rtl (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc.,,cari,be red on rever side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- --`•------ ------------------------------------------------- ----------- DATA..............----•_ -- REVIEWED BY _________- DATE r' `?}�� BUILDING PERMIT ISSUED___________ __ -------------------------------------- DATE....... rations and/or recommendations _> "i ___: __.(9_�( tr-A.�. �__......... , �.- -e -U------ w •-- ---- - - - . . 3m _6 4.c..._. .Gd ---•-T� � s G o39" 4 s �' w�© A�- f—S�(' 1y oT1`s Q�zT� o F �SNc;k r ? r , w '• ." FINAL IN5PECTION BY: ----- --- -- - ------ __----- _-_-- Dat .•-- "' _a�J..._ ...-----• '•GJ —�"� TAM �5G IJOAQUIN LOCAL HEALTH DISTRICT 130 South American Street(,&'46y 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California a 41Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1'•57 F.P.CO.