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'A. OLICATION FOR NITATION PERMIT Permit No. til i (Complete in Duplicate) S� l Date Issued Application is hereby made o the San Joaquin Local Health District for a permit to construct and install the wok herein described. IS application is made in ompiiance with County Ordinance No. 549. i i� ) JOB L04 TION AND LOTION ___ _. -J-- -----G f r ----------------------------------- Owner's Name __:. --------- ---- - honed Add r ss .Q._ --------- -------- -- C ' - 4 y ------------- Contractor's ______-Contractor's Name_ 1 _ Installation will serve: lResidericc. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 4----'Number of bedrooms _�__._ Number of baths I__-_ Lot size __ Q__I_l a_ { ---------------------------- Water Supply-' Public systema Community system ❑ Private ❑ Depth to Water Table CIF_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ElClay Loam E] Clay E] Adobe 91 Hardpan E] Previoto us Application Made: Yes ElNo [E New Construction: Yes 0 N o ® FHA/VA: Yes L] No E]TYPE 'OF INSTALLATION AND SPECIFICATIONS: } r{No septic tankor'cesspool permitted if public-sewer is available within 200 feet.) /4 - I ) _ .-- - Septic.Tank: Distance from nearest well_________________Distance from foundation__________________-Material___-.____-E___________.._____-- 7�.. No. of compartments--------------------------Size-------------•----- --- Liquid depth Capacity I ,`'.. ------.. isposal 'Field: Distance from nears+ well _._Distance from foundation______________`____.Distance to nearest lot line_. _______ ❑ Number of lines----------------------------------Length of each line- ----.Width of trench_------------------- ------------ I Type of filter mate:liaL_______________________Depth of filter material_--._____--______-__Total,�length� ____ ______________---__--_--_--_ ! Seepage Pit: Distance to nearest:well _4�`----___._Distance from foundation___f��___ I ____-.Distance to nearest lot•line__, f7 ` r � Number of pits------------ -------Lining material__ ----- - �-�.--------.Depth---=+-�--�------------------ ' Size: Diameter____._ Cesspool: Distance from nearest well_________________Distance from foundation------------- material__ ❑' Size: Diameter Depth - i Li uitl Ca aci} G+ I qp y----------------------------gals. Privy:' Distance from nearest well ---- ____Distance fromearest building4 --------------------- - ❑� Distance to nearest lot -------------- - + t -------- - - Remodeling and/or repairing {describe):----------------Irt ----- _ ---------•-------•---------- t i = ---------- - ------ - ------------------------------------------------------------------- •-------------------=----------------------------------------- at I ave red this icatib' n and that the ordinances, laws and rules ules andare regulations olf A6 San Joaquin L cal Hel11 l h"D one in accor.'d�tirice with San Joaquin County f` g st �p`,� ---------------- (Signed) - + 42 {Owner and/or Contractor) J�1 SY: ' ----------------------- { liot, = = Title-- " --' ---�- - (Plot plan, showing size location of system in relation to wells, buildings, etc., can"be placed 'on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE----,, -Y , ---------------------------- REVIEWED BY ----------------- ------- DATE r`� ,,_ —7 BUILDING PERMIT ISSUED —--- �.j -- ---------------------------------------------- DATE---------- - , Alterations andf or recommendations: ------- � s� - ------------- Alterations -------- f ------- ------DE-FT- -,k-------- - 2S - ` l -----------------------------•------ _______________________ P.__'_� ___________________________ ----------------------------------___._._ ______________________________________ -1''i ----------.__. �4 FINAL INSPECTION i�_ „ - -----------Az------------- Date---- ------- Ar SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.Co- w i Bl '