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-*" FOR OFFICE USE: -----------------------4,- -;77 APPLICATION FOR it No. 161M.a. ----------------;�------------------------------- SA W� l ATION PER_YIT ;d�e�' 94' Perm ------------------------------------- ------------------- (Complete in Ddplicafte)`,, Date Issued tf' �Q From 1 1. --------------------------------------------------------- This Permit Expires I Year Fforin Date Issued Application is hereby made to the San Joaquin'Local Health District for A permit.to construct and install the work herein d6scrUid. This application,is made in compliance with County Ordinance No. 549. JOB ADDRESSAN LOCATION.----- ----------------------------------------------------------------------------------------- Owner's Name- f. " ------------ -- phone-------------------------------- -_ ___ __- - - - ___ - . X� - ----------- Address.-, - -- ---- -------11r, --- ---- - -- -------------_------------ ------ ------------------------- ------------------------------------------------ 0 ---------------------------------------------------------------------------------- ------- Phone----------------------------------- Contractor me..!:-------------- k Installation will serve: =Residence rtment House ❑E] Commercial ❑E] Trailer Court ❑[3 Motel ❑[:] Other E] i qa .6-5- )1( I,S_Z�111 Num df-living units: __--!-_: Number of bedrooms __._Number of baths Lot size ---- ------ --------------------------------------------- Water Supply.Public system V Co"Mmunity system El Private F1 Depth to Water Table -------- ft. t - . fl, Character-,of7oil to a depth of 3 feet. Sand 0 Gravel L] Sandy Loam [:] Clay Loam 0 Clay ❑ Adobe Er'lTa-rdpan ❑ s `1 ade. New Construction: Yes L21`lNo E] FHA/VA: Yes E] No El Previous App icafion M v! (If yes,d #____________________1------------- ---- N I V I �s j TYPE OF INSTALLATIONIAND SPECIFICATIONS: f (No septic tank or cesispovol.pedrWifted,if public sewer available within 200 feet.) M t ----------------- Se t' T k: ance _,mitance from flun ------------- a . tk,, 4mlDist �i ,T, AMON-, timb"*� 1110��45. o ------- uid depfh--.-- G� rTmen s 4A-- ---------Capacity--------- ----- Disposa Disfancefrom neatest weli-AW rDi. sfance from Tuncla ton- OW-------Distance to nearest lot line ---------- Number of lines__.________. Length of each line'- -------Width of french - -- -------- ----- rType of.filter ateria _k __A _.__Length filter material-- ------- Total length'- ----------------- 0 rRi-al a Seepage Pit: 11 Dist6Re,jo-ne-arest well---------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Humber of p:fslo&_�, -?,.r------Lining material--------------------.--Size: Diameter-------------- .........De'pth------------------------------ Cesspool: Distance from nearest well---_--__-.-_:-_Distance from foundation-__--____.-_____.Lining material------------------------------------ Size: aterial------------------------------------ 0 Size: Diameter---V_t -,Al ...... \JA --------------Depth------------------------------ ........ ---_Li Capacity----------------------------gals.Privy-. Distance from nearest well_______________________ ---------------------------Distance .from nearest building___.__.___.________.__________'__._____.. ❑ Distance to nearest lot line---------------------0---------------------- ------------------------- ------- -------------------------------------------------------- V)• Remodelingand or repairing ------------------------I----------------------------------------------------------------------------------------------------------------- , j Q01 -------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- ---------------------------------------------------- f - # A ---------------- ------------------------------------D.. ------------------------------------------------------------------------------------------- ------------------------------------------------------------ 's'anc FD Distance ,:or e pair 0 ----------------------------- ----------------------------------------------r--------------------- -------------------------------------------------------------------------------------------------------------:---------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,A§ ate;laws, and rules and regulations of the San Joaquin Local Health District. ,a (Signed)--- —-------------- --------------------------------------------------------------------------(Owner and/or Contractor) .:, :: -- - ontractor)---------------------------------------------j_(Title)------------------------------------------- - - - ---- ------- (Plot plan, showing size of lot, location of sysfem.in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY' APPLICATION ACCEPTED BY.....------- --------------------------------------------------------- DATE----- _" REVIEWED ATE-----REVIEWED BY------------------------------------ ------------- ---- ------------------------------- --------------------------- DATE-------------------------------------------------- BUILDING PERMIT ISSUED----------------------_,_:-------------------------------------------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations:-,------------- ---------------------------------------------------------------------------------------------------------------------------------------------- 2 -6 ? -- !r 6 --------�._ ___ ------ ------------------- ---------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------ - - -- --- --------- --------- ------------ --------------- ----------------- ------------------------------------------------------------------------------' -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:----- 3.10 Date---- ---------------------------- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave, 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 IREVISED B-59 3M 3-'63 F,P.00.