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rVK U1-l­_D!<USE. <br /> r <br /> -------------------- <br /> APPLICATIONk FOR <br /> t ,.SA,.NrITATION PERMIT Permit u . q./.r <br /> ! ye._q_-{Compete maDupcate) <br /> t T <br /> s ► ___!1c ' r, <br /> ------------------- ---- '------- - -- - -- - '......- This Permit Ex fires T Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Healfh District for a permit to construct and install the work herein described: <br /> This application is made in compliance with County Ordinance No. 549. <br /> F <br /> JOB ADDRESS AND LOCATION]------i _ <br /> - h <br /> Owner's Name-------- <br /> -Wt jtAddress -..__---- I <br /> =- = _.....Phone---•-------------- -------------- <br /> - •. 1.1 ' 1 .. - . <br /> Contractor's Name------- �11 R_�-- I }} <br /> � artment House Commercial i Trailer Co-------------------- PhoF1e.._ ................... <br /> , <br /> --•------- • ---- __ <br /> Ins#allation will serve: Residence ❑ <br /> t ;rt ❑ Motel Other ❑ <br /> i Number of-livin� units: _11 <br /> g 1____. umber of bedrooms _-_I_-_ Number of baths _ y 10 0 <br /> �!._.__ Lotsiza __---_ _-_ <br /> Water Supply: Public system Community system El Private ❑ Deoth to Water Table - -- ; .1 <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam'❑ Clay .Loam❑ Clay KAg 0 K <br /> t y Adobeardpan Q <br /> Previous Application Made: (If yes,date_..________________J No New Construction: Yes �o ❑ FHA/VA: Yes`,❑ No # <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public se eyes available wit hin.200 feet. <br />" Septic T : Distance .from nearest well___ ��► istance from fo ndation___� f����` <br /> i� 1. --.Materr------------------------ <br /> ---------- ------ <br /> No. of compartments----- ---- Size_._ --_----__ :- Liquid depth------ -------_--Capacity_ f}f� <br /> - 10 -- <br /> Disposal Field: Distance from Weare t well Distance from foundatio <br /> .. n� '____.Distanceto nearest lot line__- �` <br /> Number of lines_--- '— t a <br /> _____ILength of each.line _ _-- -�Wrdth;of trench.__ .�1 <br /> Type of filter material_._._ ---"]Depth of filter r'naierial___,_ rr Y' <br /> - r V-------- <br />`�. Total Length----- ----------------------------- <br /> Seepage <br /> Pit: Distance to nearest well"_ _________}Distance from foundation__..___..____!--t1pistance to nearest lot fine______.__"___... <br /> ❑ Number of pits----------------------Lining material.-----------------•--Size: Diameter _ Depth---------------_-••-- <br /> rf _ <br /> Cesspool: Distance from nearest well____ _________�Distance from foundation___.__________ 77Li rn ng material__.________ <br /> ❑ Size: Diameter. -Depth ------------------- ---------- ---Liquid Capacity----------------------------gals. U <br /> Privy: Distance from nearest well--------------__------_____ Distance from nearest buildingEl <br /> Distance to nearest.lot line . <br /> -----•------------ ---------------•--------------- <br /> Remodeling and/or repairing (describe):---------------- ------ <br /> I <br /> •-------------- -----•----•--------•-•--•- --------------------------- <br /> --------- •-----------------------------•---• ------ <br /> --------------- •------••----••----------------------- . •-`. ---•---•--- -- <br /> _j---------------------------- <br /> =--------- ----•------------- <br /> ----------------------------- �Ejf <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in-accordance with SanF Joaquin County <br /> ordinances, State ws, and rules and regulations of the San Joaquin Local Health District.9, <br /> (Signed)- -- , <br /> ---------------- ----=--------- •---•---------------(Owns <br /> 'By:-------------- ----•- - - -- •-- .. r /or Contractor) <br /> (Title)--------------------------- <br /> t <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 ONL'r 1 . <br /> APPLICATION ACCEPTED BY _.7_)_)_1•----�--- ---- <br /> DATE_ j= "1� <br /> REVIEWED BY ------- -------------------- ------------••---------------------------------- --- DATE-_--------------- <br /> BUILDING PERMIT ISSUED`--:.----•----------- ------••-------------------- <br /> - - --------------------------------------------- - ---------------•-- DATE---------------------------------I-----.....Alterations - <br /> and/or recommendations:''_____ ---~-"---".. <br /> ------------------------ -------•--------------•----••-----•-----•--------.--------•----------- • <br /> -•-------- --'- --- <br /> _ -------------------------- <br /> A= <br /> ---- <br /> 4 -Y. <br /> ....... -At <br /> -- -----------------------• <br /> � <br /> FINAL INSPECTION BY:._ <br /> ------- --- ----•----- Date-------- <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American street 300 West Oak Street <br /> 134 Sycamore Street 205 Wast 9th Street <br /> Stock+on,California j Lodi,California Man+eca,California <br /> Tracy,California <br /> {} 6 <br /> I,�E�•9 REViBE�B•44 F.P.CO.IIM 6.60 <br /> !J <br /> ' 4 <br />