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APPZICA ONC3 NITATIO ` N PERMIT - (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compf iance with County Ordinance No. 549. JOB ADDRESS AND LOCATION___ _- ,- Ot ---------------- ------------- Owner's Name----------- - ----a!,S-,r ®m- ?.- ---- - Phone ------------------------ Address__________________ _ �- _ -- - - -----�+�+�,,.� �--------------------------------------- Contractor's Name----------------_------•---_ ----- -------- -------- --- Phone ----------------------- -------- ---------------------- ---------------- nstalfation will serve: Residence Apartment -- ❑ --- --artment House Commercial El Trailer Court E] Motel ❑ Other ❑ Number of living units: .❑ Number of bedrooms 0 Number of baths 4 Lot size__________ Water Supply: Public system Community system ❑ Private ❑ F Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑" Clay ❑ Adobes Hardpan ❑ W TYPE OF INSTALLATION AND SPECIFICATIONS: ; (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I TSeptic Tank: Distance from nearest well_________________Distance from foundati ---.-.Material------ No. of compartments___________4z • Capacity___ _ aGZeZ WX�r__X__ _Liquid depth_ Cesspool: Distance from nearest well-----------------Distance from fount anon__________________-.Lining material______-_________ ❑ Size: Diameter---------------------------------------Depth------------------ ----------- ---- - ---------------- Privy: Distance from nearest well1 _Distance from nearest building g ---------- Distance to nearest lot line___________-_______ ---------------------------- +. Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot -__- ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------------Depth---------- --------------- Disposal Field: Distance from nearest . j Dis nc fro foundation______��_------Distance to nearest lot line ________ Type Number of lines '"`--------_ Length �.-----------�'OCl-Width of trench---------�td "I T e of filter material______v___ __________bepth of filter material______-`P- 'Remodeling and/or repairing (describe):--------------------------- _ _______________________________________________________________________________________________________________„_________-___________-______________-__-____-____-___________.__Y_._.y. 1 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. _.tom (Signed)___x___. � ---------------------------------------------------------(Owner and/or Contractor) BY---------------------------------------------------- ---- -- -- - - ---- --- + __(Tale) (Plot plans, showing size of lot, location of system in relation to wells, buildings; etc., must be filed with this application). FOR DEPARTMENT USE ONLY v APPLICATION ACCEPTED BY_______________________ DATE------- REVfEWED BY---------------- ^- 67-1 -_E`D--------------------- ------------ --------------------------------------------------------- BUILDING PERMIT ISSUED ---------------- ----------- DATE -- ------------------------------------- ------ -A-------------i-r------- ---� DATE------ _ Alterations and/or recommendtfons__ ______ _______ a - rte - _ io -- =- - F � � ------ ------------- ------------------------------------------------ _______________________________________-_-_____ v _____ _____________ _________ ---'�-��-�----�-�------�---��'��--------�*»JY!�_ll.*�✓-----'.` /ISA------- -------------------------------- -------------------------------- ---------------- r ---------------------------------- ----------------- PERMIT No. ISSUED ______(Date) FINAL INSPECTION BY:------- JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street i 9-50 W4639 Stockton, California �-9-2Ar1