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F013r QFFICE USE: ------------------------------------ --------------I------------ --- ---------------- ------ - (Complete in Duplicate)/ This Permit Expires 1 Year From Date Issued Date Issued 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 compliance with County Ordinance No. 549. JOB 'ADDRESS AND LOCATION..--- 7�d-- - -,If� - ----------••---••---------------------------------- Owner's Name------------Z-1-_�--- - -- ------ Phone_ -- pp- Address---------------------------------------Q___ ....... -------------------'---------------------- -•----------.....------------------------------------ Contractor's Name_______________________ 't •----=-• - -----------------------------...- -------•----•----- Phone----------------------------------- a Installation will serve: Residence MApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___-_(__ umber of bedrooms ____�-Numher of baths._:__. 1~Lot size ------ ---- 11 / .� f, Water Supply: Public system Community system ❑ PrivateA❑ Depth to'Water Table -(-J- ft. Character of soil to a depth of 3 feet: Sand E] Gravel El -Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [p--'Fiardpan ❑ Previous Application Made: (If yes,dote----__--_.--_.-�-) No New-Construction: Yes K�- �o ❑ FHA/VA: Yes ❑ No ®� TYPE OF INSTALLATION AND SPECIFICATIONS: ' W (No septic tank or cesspool permitted if public7sewer is available within 200 feet.) f Septic T Distance from nearest well-----_-_______Disfan e fro rp foynation_.-.-_r1_3 Ma erial---- __------___________ ___________________ No. of compartments---------- - Sizes' � r d --------------Capacity--- � � Disposal 'eld: Distance from nearest well....__=�-----Distance from foundation-----------/ "_-Distance to nearest lot line__- .... OD Number of lines----------------_�_----___---.---_Length of each line__________�42-----------Width of trench--------- _ __________.-____-____ Type of filter material PPA-Aad<Depth of filter material-.-..� ��_-_____Total length---------- 4______________----_-_-_ O Seepa it: Distance to nearest well _________ ---------Distance om Distance to nearest lot Number of pits-- '__ Lining material--- f:G�__Size: Diameter_______.__-.__-_Depth__.___, , "'___-____---_ t Cesspool: Distance from nearest-well------ -__-_Distance from foundation--------------------Lining material------------------------------------- ❑ Size. Diameter--------------------------------------Depth-----------------•----------------- ------Liquid Capacity----------------------------gals. r Privy: Distance from nearest well------_------------------------------------------Distance from nearest.building-------------------------------- ..___-— P ❑ Distance to nearest lot line - ------------------------------- ---------- ------------------------------------------------------------------------------------- ------ 3 Remodeling and/or repairing (describe)------_;.- -. ----- __ ._ ......¢;�___ ------------•----------•-••------------------------------------------------------- ------------------- *------ ------------------------------------------ ------------------------------------ ------------------------------------------------------------------------------------------------------------------------------- •--------•-------------------------------------------•--------------------- ----- .- ------------------------ --- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 nd regulations of the San Joaquin Local Health District, f (Signed)------------ }� (Owner and/or Contractor) 3 ----------------- 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 APPLICATION ACCEPTED BY-------- ` fe x DATE------- J _ ------------------- -- ---------------------------- REVIEWED BY-------------------------- ---- - - ---------.. DATE---------------- ------------------------------------------- BUILDING PERMIT ISSUED-------------------------------------------------------------- DATE______--____-_.._____-. ------------------------- - ----------------------------------- - --------- ------------------------- Alterations and or recommendations---------- ----------- -•-----------------------------------------------------------------------------•------------.-.---------------------------------------- '�. e,-�------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- --------------------------------- -------------------------------�----- ----- --------------------------------- =---------------------- FINAL INSPECTION BY:.........(-A 2. - ------ i r Date-------7. /-1--J ---------------------------- --- ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hosellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9Th Street �k. Stockton,California Lodi, California Manteca,California Tracy,California r -, C9.9 REVISED B-59 3M 3-•63 F.A.CO.