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FOR OFFICE U5 r �' • 51 114. _------------- `�..----- APPLICATION FOR p►NITATION PERMIT Permit No. ....... _ _. --i- -`.l-L-- -to ------ ---------- Complete in Duplica#e� 7l/ 0 f Date Issued --'--------7-ka--- This permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein desrib d " This application is made in compliance, i h C un . Ordipanco No. 549. JOB ADDRESS AND LOCATION Z '�Owners Name . �-------------- Phone_.r�d.. -- i Address---------------------y`/-a F�?...............4 t- --- . ----------- ........... -------------------•-------------------_-. Contractors Name----------------------------------- ST '-"" _ - Phone Installation will serve: Residence [' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -/--- Number of bedrooms ._YNumber of baths ___,E___ Lot size Water Supply: Public system ❑ Community system ❑ Private ® Depth To Water Table 1r+ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam,{f Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: (1f yes,date--------'- No ® New Construction: Yes ❑ No [R' FHA/VA: Yes ❑ No ®' = TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--- _____Distance from foundation.--__l o-------.Material___-_-.4 154 No. of compartments--- ------Size...... -, -- --Liquid depth------- �-----------Capacity-------r' ••`� Disposal Field: Distance from nearest well ___-„r_P_Distance from foundation__..__.�.....Distance to nearest lot line_____ (o Number of lines----------------r_/---------------.Length of each line--------Zess-xv.......Width of trench-------?-- •----_------ Type of filter material.____ ,.,r Depth of filter material_. _Total length................. Seepage Pit: Distance to nearest well----------------------Distance from foundation_........-----------Distance to nearest lot line......... 4 ❑4 Num6er of pits----------------------Lining material-----------------------Size: Diameter------.---------- :=--:.Depth----------------------••--------- Cesspool:� +'Y'' Distance from nearest well--------------_Distance from foundation--------------------Lining -- material____--______--_--.___________________ ❑ Size: Diameter------------•-------------- ------Depth-------------------------------- - -__-Li Liquid Capacity-------..._...-----------_gals. . ' � ______________Distance from nearest building--------------------------------.- Privy: Distance from nearest well___________________________________ ❑ ... Distance to.nearest lot line--------- --------------------------- ----------•------------------___----•-•----------•-•---------------------------------------------------- Remodeling and/or repairing (describe):-___- - --------------------�---------- �” r �� -_...._....--. -___.-- �---- -------------- ...---•----------------------------------------------------------------------------------------------------------------------••----------------------------------•--•------ r 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, 4(Signed).-- -r- (Owner and/or Contractor) By-----•---•----------•---------------------------------------------------------------------------------------------------------- -----(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc:, can be placedron reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------•---;; � -- - --- DATE /�� •f � REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE__-------------------- -----I —-• ---------•----------- BUILDINGPERMIT ISSUED----------------------------------------------_---------------------------------------------------- DATE------------------------------------. 1--------•------------- Alterat' ns and or recommendations:-------------------------------------- --------• - -------•-_---- ---------•--------- --- _.... - ---------- _ ----- ------------ _5: �.��------------ -� �/1, --- ---- -----• -------------- --------•-5.- -,��-•4. - --------/�----`-- ---- --------- - ^�' ---- ----...._. ........ a '`" .7ra...r.. `f ' ------------------------------- l 7`�V_ .FINAL INSPECTION BY: Date------ '- SAN JOAQUIN LOCAL HEALTH DISTRICT f130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS _