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FOR OFFICP USg: �C z 3R' .. �Sl y --------------------------------------------------_----- PLICATION FO ��►�IITATION P IT Permit No. ---•-----=-- -..._... ---------------------------------- -------------- (Complete in Duplicatel. Date Issued ----------------------- is Permit Expires 1 Year From Date Issued Application is hereby made to the Sen 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. , .+ /7. 441 R-2 ----------------------------------•--------------------------------------•----•-••-•-- Owner's Name------joky-......pR-t.M_ere�-•• -- Phone. _ ' ...... Address.................../--.fJK4.... ----------------------••---•-------....-----------------...---•----........ Contractor's Name.................. .HIRi -----------------------------------------------------------------------..--------•••------------•-••------ Phone................................... Installation will serve: Residence ET'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Qther ❑ t / Number of living units: _I____ Number of bedrooms _ Number of baths __1... Lot size .--- _. ---------------------- Water Supply: Public system (V Community system ❑ Private ❑ Depth To Water Table I �ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [.,Clay ❑ Adobe[r Hardpan ❑ Previous Application Made: (if yes,date____________________) No � New Construction: Yes [300"No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weIIN&WF..Distance f om foundation___L. __.__.._..M t vial............. '_ ........_....... No. of compartments_----__-� -------._Size....3A.*.X41__Liquid depth..._ : ____Capacity...... --- )... Disposal Field: Distance from nearest well N/N64CDistance from foundation....&v_'......Distance to nearest lot line..._�!..... Number of lines______.__.Z. __________________Length of each line-----•.} _-.__._---_..Width of trench......_.-��"............. Type of filter material. E' --_---__-Depth of filter material...../0~__-_-__Total length.............19................._... Seepage Pit: Distance to nearest well__N01/�_---Distance from foundation...A!_..._._...Distance to nearest lot line.... _.�_..... f� Number of pits---..-f-------------Lining material-'Pe-mot--------- Diameter-__--mss --'-.-...Depth------- -7............. Ch Cesspool: Distance from nearest well.................Distance from foundation____-._- __:_:_.Lining material ..-___--_...__-__----I.............. ❑ Size: Diameter--------_--------------------------Depth----------------------------------------------------Liquid Capacity............................gals. Privy: Distance from nearest well-----------------------------------------_-------Distance from nearest building.......................................... ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------*........................... Remodeling and/or repairing (describe):_-_:__!i_ylTr� _.__.__-,Ir -� -9.._ tu7 ------------•---•---------------------------------------------------------------------------------------------•----------------------------------•------------- -------------------------------------------------------- -- -- --- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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) By:.......... l- -= ---------------------------- -----------------------------------------------------------------(T'ifle)---------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). TR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -------------------------------------------- DATEj.2_...-^ �._2...---------.._....... REVIEWEDBY-------------------------------------- -------------------------------------------------------------------------------- DATE.............................................-------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE..........................................................•-- Alterationsand/or recommendations:............................................................................................................................................................... ---------•---------------------•--------------------------------•------•.....----------------------------------------------------------------------------- --•--•----•-----..----------------•-----------------...------------ --- -------•------------------------------- --------------------------------•------- -•-------••--•--•-••-••---•-•-••-----••---------•--•-•••--•-----------------•---•-•-•--•---------- ......... -------------------------------------------------------•-- ------------------------------------------------------------------------------------------------------------------------------------------------------- 1 FINAL INSPECTION BY:-----� � -,:--• - -------------------------------------- Date-----�---�--------�--.�L...._--._._�_�-......................... v SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 265 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS