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FOROFFICE USE: � /r L � 0 � ------------------------------------------- ------------- APPLICATION FORL 5AN1 TION PERMIT Permit No. --•-_•--•-•--- ----•-- ------------------------------------- ----- --- (Complete-in Duplicate Date Issued 7--� �- _.--_. _ .... This Permit Expires 1 Year From Date Issued 1 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 complianc with County Ordinance No. 549. �SCgLpr� ADDRESS AND LOCATIO ``�11� - 7 f�i_1= 1? - f(7 11_2-=z•�, --21 ------------------ JOBd 'l�FS Owner's Name-------------R-y----------- ' ------ _KV!-- ------ ------ --------------------------------- ---- PhoneLl�P�- ��®6 Address-----------------F_T -----j--- ----iU!Q -------q-7 ----- ---------��K-�A-��:..._. ------------------- _---_----------•--------------------------- Contractor's Name------ ------31Aff - '•..----• ---•-------- ---------- ------ ------- -----------------------------------------.--.-. Phone_------_-------------_-------- Installation will serve: Residence ®Apartment House ❑ Commercial I] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ Jt___ Number of bedrooms 2-. Number of baths--)... Lot size ___ _____________________ Water Supply: Public system ❑ Community system ❑ Private J�Depth to Water Table _-..__ _ ft Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam lay Loam ❑ Clay ❑ Adobe ❑ Hardpan [!r-__� Previous Application Made: (If yes,date___________________ ) No New Construction: Yes D-T-IN, ❑ FHA/VA: Yes-K--'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: W (No septic tank or cesspool permitted if public sewer is available within 200 feet:) Septic T Distance from nearest well-------- from foundation--------fa----- Materia ` n --.53 x_t*_ _x__5_. Li uid de th----- f O_CQ-• No. of compartments_.-__.._'�„�_ Size_ q p '�__ �-. Capacity.___ ___. vJ p Distance from nearest well.-5- _-Distance from foundation_______. _ -�Q_--.Distance to nearest lot line______.___-_ � Number of lines _____________f _____.- °_-Length of each line_ _._.-__. _f.-�_ Width o£ trench___.__ f r -"� Disposal ie L�- f f- -- ------------- t/► Type of filter material-_._; �.0 Depth of filter material_._ j?- ---___._Total length----_-._-___��_____________________ C7 -- r Seepage Pit; Distance to nearest well- - -10.- -......Distance from foundation----- ______ Distance to nearest lot line.-�__-____._ ❑ Number of pits___ ....i------------Lining maferial. .- 60K..-__ Size: Diameter_.�.�._-�__-Depth-----��._�__________--_ Cesspool: Distance from nearest well ________________Distance from foundation................. ..Lining material.____--_-.-.____.-.-__-__________-_. ❑ Size: Diameter- -- -------------- ---------------Depfh----- -------- -----------------------------------Liquid Capacity----------------------------gals. (D Privy: Distance from nearest well----------------------------------------------___Distance from nearest building ❑ Distance to nearest lot line .-------------- - - ------- - -------------------------------- Remodeling ---------Remodeling and/or repairing (describe):------ -- ---------------------------------W-W--------------------------------------W-W--------- -------- ---------------------------•----------------- -------------------------•--------------------------------------------------- ---------------------- ---------------------------------------------------- - ------ - -------------- ------------------ ------------------- _-Z ------------------------------------------------------------------------- --------------=---------------------------------------------------------------------------------------------------- ------------------------ ' --------------------------------------- --------------------------------------------------•--------------------------------------------------------- ------------------------------------------------------------ ---- -- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta411.aws, d r s and egulations of the San Joaquin Local Health District. (Signed) ---------------- ------- --- - ------------------.(Owner and/or Contractor) By:----------------------------------------- ------------ ----------------- --- --- ----------------------------------{Title)----------------- -------- -------- -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY �7 APPLICATION ACCEPTED BY---- T�_(-R.-- ------------------------------------------------------ --------------------------------------------- - - -------------- DATE-------- { REVIEWEDBY----------------------------------------- --- ------------------------------------------------- ----------------------------- DATE.----- BUILDINGPERMIT ISSUED-------- -- ---------------------------------------------------- -----------------------------------.. DATE------------------- Alterations and/or recommendations----------- ----------- - ---------------------- ----------- ------------------------------- - ----------------- - ---------------- ------------------------------------------ ----- ------------------------------------------•--------•----------------------- ------------- --- ------------------ ------------ - ------------------------=--- --- ------- ----------------------....--------- ---- --- -------- ------------- FINAL INSP -Q Date --- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 20.5 West 9th Street Stockton,California Lodi. California Manteca,California Tracy,California 5.11.92M 1-67 Vanguard Press