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IFIR OFFICE USE: -----------------� ao�' -- � --------------- /_--_-______. APPLICATION FOR 5AWATION PERMIT Permit No. ...17 :(r __- (Complete in Duplicate) 1 __________ _____ _._`_._-___.___ This permit Expires 1 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. 4 JOB ADDRESS AND OCATION`�_ ------- --- ----------------------&--------V----Z------Ael_ ------------------------------------*----------m------------------------- OwnerName - = - ----------"--- - --- --- -- - - --- ----------- Phone---------------------------------- Address = t't p ------•--------•----------------------------- F ------- I �i�f�try]ri Phone. Contractor's Name------------- -- ---------------------------- - ----- Installation will serve: :Residence Apartment House ❑ Commercial ❑ .Trailer Court ❑ Motel [( Other ❑ F Number of living units: ---t--- Number of bedrooms -4-- Number of baths Lot size Ae�;?_-y_43 W---_________________._____ Water Supply: Public-system ommuriity system ❑ Private ❑ Deptli to Water Tabl�� ft. • ,.r Character of soil to a depth of 3 feet:' Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay [❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date_-------ii"`.._"_1 No [T'New Construction: Yes eNo ❑ FHA/VA: Yes ❑ No [E_� TYPE OF INSTALLATION AND SPECIFICATIONS: ; (No septic tank or cesspool permitted if puLlic sewer is available wifhin 200 feet.) 4 ' Septic Tagk: Distance from nearest well------ Distance from foundation__/Q__(--------Materia#--_.�__-" No of-compartments ----- --------Size---d(_ -_5-----1_Liquid depth-__4--°---------------'Capacite �,C-0_- - , Disposal Field: Distance from nearest well- - " --_---Distance from foundation_�9__E__________Distance to nearest lot line________________ Number of limes__-_1:w�__- :___---___Length of each line---_1?l.7______----------_Width of trench-_A..-f "-"----- "__ Type of,filter.material___-- 1-1?OS �t____Depth of filter material__1r..__---_____.-Total length___,/K"v___________________________ _ d x r - - .�• Seepage Pit: Distance to nearest well__' '_______Distancm foundation__ U_----------Distance to nearest lot line_____.___ Number of pits--,""._ _-__-__:Lining ma#erlal____�-_d�_._ _-.Size: Diameter__-_ 3_ `_.___-.Depth__.__.___- -�_�_-_______ W Cesspool: Distance from nearest well ,_________Distance,f.rom.foundation_-_- "--____ v - Lining V1El . materiatl------------- ----------------------- Diameter Size: ------------------------ ----------De th------------- ---------------- -----Li uid Ca actY ----_-gals. Privy: Distan-ce from nearest,well---------------------------------------------------Distance,from_nearest bu0cling------------------------------------------ El' Distance to neares�t�lot line. t Remodeling and/or repairing (describe):_--"___________-____-__ - F ------------ ------------------------ -------------------------- -----------=-------_----------`- (Vq� •------ --•--------------------------------------------------- ---------�------------------------------------------------------ -----------------=--•--'•----•----------•-------- --• f. s---------------•-------- -------`•--•--------------- - - --------- -------------------------- - -•-------- ----------------------------- t ----------- ------------------------------------------f---•--------------------------------- 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)---- 7 S { Contractor ' BY- -------"---- -------------------- --------------------- ----------- ---•-----(Title)---------------------- ------------------ - - - - (Plat plan, showing size of.lot, location'of-system in relation,to,wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY�;_ te:e_.- ------------------------------------------------------ DATE---- = "4' ---------------------- REVIEWEDBY-----------------------------------------=---------------------------------------------------------------------------------- DATE..-._..-----•--------------- --------- BUILDING PERMIT ISSUED----------------- - ------------------------ DATE ------/�, Alterations and/or recommendations-__.--: :- ` ___________________"""-_. i _ - = = .- Y ---- € 1 ------ ----------- _ FINAL INSPECTION BY:_. Y -�_ Date---- -- a_��__._.� - --------------------- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT } 1601 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E5 9 REVISED 8.59 3M 3•163 F.P.CQ.