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FOR OFFICE'SE: <br /> --------------------------------- ------- ` � Permit No. .,�� <br /> � <br /> ---------- -------- - ------------------- - <br /> APPLICATION FOR5�Ni ATION PERMIT <br /> (Complete-in Duplicate) 3--_a� ---- <br /> ------- -- ---- ----- ._. ---- - �' Date issued ._ <br /> - ---------- - <br /> This Permit Expires 1 Year From Date Issue <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. t <br /> JOB ADDRESS AND LOCATION------- ---- <br /> Phonei4,aa�!_ _W-t ---------------------------------------- ---•-----------------•------------ <br /> Owner's Name-------- ��Y '��'- 'r----------•-- --------------- - <br /> Address- ------ <br /> . ._//_ � ---=---------------- <br /> Contractor's Name-_-.1y-�,.li-l",_---- ----------------- ----------------------------------- ------- <br /> Phone <br /> Installation will serve: Residenceapartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> 17 <br /> Number of living units: _. ..-__ Number of bedrooms <br /> Number of baths / Lot size ---j > - �._e -------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ft <br /> Character of soil to a depth of 3 feet' Sand E] Gravel ❑ Sand Loam El Clay Loam [I _Clay ❑ Adobe ardpan C3 <br /> Previous Application Made: (If yes,date-----------------_ ) No New Construction: Yes g­No O FNA/VA: Yes E] No Ejj�j <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: ` <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) • <br /> rv -r - -------------------- <br /> S <br /> Septic T k: Distance from nearest well_JrO-.---Distance from foundation___f--------.Materia:...__ / _____.__. - <br /> l� q p 4 � -- -- p y <br /> No. of compartments_.__.._. _ Ca acit .��_-_-- -- <br /> � ----- Size-/ _�a.�x:�� -�----Li Liquid de�h ---- * - <br /> _ i <br /> Disposal F' Distance from nearest weli_ _L .__-Distance from foundation.-_/.0------_._Distance to nearest lot line_r�-- ---. <br /> Number of lines--------- ,--- _ - ---- Length of each line_..---'L -------------Width of trench__-_- �? _V ------ <br /> Disposal <br /> Type of filter materia . j_. _. _--Depth of fill lter material -- ---..-Total length___. _ --------- <br /> C� Dieo nearest lot <br /> Seepage s#: Distance to nearest well-_ � Distance fro foundation... ... .......... <br /> 1,S ----De f .5, <br /> Number of p�fis... -..�--- -._.Lining melena_-- -.�--- -�--------- Size: Diameter-- -- _ _-- p <br /> F Cesspool: Distance from nearest well ...... Distance'from foundation--- ------------- - Lining <br /> Capacity t gals. <br /> ❑ -----De th--------------- ---------- ------- ----- q p y------------- ------------ <br /> 5ize: Diameter_ __ - - p - �--- " <br /> ! Privy: Distance from nearest well...................._ <br /> ------Distance from nearest building------- ---------------------------------- <br /> Distance to nearest lot line .------ ----------------------------------------------- <br /> { �l. r/�d'�.'lP•-�'_ �p : -.mss <br /> Remod ling and/or repairing (describe):_..-- -*��-��� - �`"_�---- <br /> `4 ----------- ----------- --------------------------------------- <br /> ------------ <br /> - -------------------- ----------- ------------ <br /> - ----------- -----------------��--- `Pp ,with San Joaquin County <br /> I .hereby Certify that 1 have prepared this application and that the work will be done in accordance. ` <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> .- __----. -_---------------- --{Owner and/or Contractor] <br /> s (Signed)------ --- ----- h - : <br /> BY� - --- -----------(Tifi )-------------------------- --- ---- ------.--- ----- ----- <br /> e . <br /> (Plot plan, Showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> PATE..... r -(��-------------------- <br /> - -----APPLICATION ACCEPTED BY.---. <br /> REVIEWEDBY------------------------------------ -------- --------------------------- ------------ ----- ------ ------------------ <br /> BUILDING PERMIT ISSUED-------- ----- D A-------- <br /> -------------------------------------------------- <br /> Alterations and/or recommendations: ._..... - <br /> - � - <br /> - <br /> ^ + - Pate-...- ------------ ------------ <br /> FINAL INSPECTION BY:- L - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 911h Street <br /> Lodi,-California ..:Manteca,California Tracy,California <br /> Blackfan,California �.=; - -.� .. <br /> E.H.9 2M 1-67 Vanguard Press <br />