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FOR OFFICE USE: 4fJ -------- -_-_--- -----------____------ --------_------itP, APPLICATION. �R .MTATION PERMIT Permit No. . �s 1 --------------------------------------------------- (Corr plitte 'W Duplicate) -------------- ------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Heal+h 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 D LOCATION_,___ ..�f (�✓rF .l _> _:j t-C�% C r� Gam' - 1 --------- - ----- --------------------------------------J,�- I Owner's Name----� =1Y�. [-u�r�• � '�` I�'=C- � h e 7.ae�—. Cs�t l r Address = = ------------------ T- � _ �- sr Contractor's Name - -t-� Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer art 4 Motel ❑ Other ❑ Number of living units: --)'_-. Number of bedrooms 3__ Number of baths A____ Lot size ________________ Water Supply: Public system ❑ Community system ❑ Frivatelk, Depth to Water Table _I6 it. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (if yes,date--------------------) No ❑ New Construct ion:_Yes E].- No ❑ FHA/VA: Yes ❑ No,Q,.�, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t Septic Tank: Distance from nearest well_ Q Distance from foundation-..1_V..i_..___. Material-____________________________�_-.`_--__�7._.�__ --__-_. ______________No. of compartments Size___/_�� -I4_LLiquid ' Capacity---A 1 ^ I O Disposal Field: Distance from nearest well..�tXa_�-_Dist ance from foundation__ -___...._.Distance to nearest Number of lines---•_ -------------------------Length of each line__.57S-.-----------------Width of trench._"' __ _______ ------------------ of Type of filter material. r_ epth of filter material----Rr-'aaL,----Total length___.__O_____________________________ Seepage Pit: P 9 Distance to nearest well-- -Qp___ - Distanee from f ndation___________________.pis# nce to nearest lot line__ Number of pits....__. ------------Lininmaterial__ $ize Diameter__. Cesspool: Distance from nearest well----------_------Distance from oundation____.-----------_Lining materia!/ox¢x l ' __.___------------------ ❑ Size. Diameter--------------------------------------Depth--------------------------- ------------------------Liquid Capacity_--------------------------gals. Privy: Distance from nearest well----------_______________________________________Distance from nearest building------------------------------------------ `� F1 Distance to nearest lot line Remodeling and/or repairing (describe):---------.Wi_�i�----c,�1- _.__ -4 5 % =_._____________________________ •--------------------------------------------- --------------------------------------------------------•-----------------------••---------------•-------------------------...----- ----------------------------------------------------••-------------------•----------•------------------------------------•---------------------------------------------------- ------------,::------------------ 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) �' :. P1 1' [ -a c - `]t'-x; r _ ..: ----_-- ------.(Owner and or Contractor ^�-. .. 'ice-• „__.:._ / I By:__..._.. s. -`. ---------------(Title) ----------- - -- - -- --------- (Plot plan, showing size of lot, iota+i of system in relation to wells, buildings, etc., can be placed on re(erse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- ` DATE Vj 7 REVIEWED BY--------------•----------------------------------- -- _ DATE-------- BUILDING PERMIT ISSUED------------------------------------------------------------- --------------- DATE Alterations end/or r commendations---------------- ------------------- ------------------------ . -- s ' -- ------- FINAL INSPECTION BY: --- Date---------- � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazolton Ave. 300 West Oak St leet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California c. E5 9 REVISED a-59 3M 3-'63 F.P.Cq. iy