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FOROF.FI.CJEfl1 :3 ------------- �,� �___'.- -_ .___..____.._. APPLICATION FO _�4NITATION PERMIT Permit No. .16.� --------------------------------------------------------- (Complete in Duplicate) Date Issued _..` /.�J...3 -------.--- This Permit Expires ii 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 described. This application is made in compliance with County Ordinance No, 549, JOB ADDRESS AND ?_- -?_-^_____ ------------------- a - --•-•-------------------_-- Owner's Name---------- v•- s_ a$. -e �« -�x--- -- C � ----.��--- Phone__�_3'. -----�-•--- Address ------- Contractors Name-----------•----------_--— ---••••••Z!'---------- :-'..------- one................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Mool ❑ Other ❑ i Number of living units: -rte Number of bedrooms,,.- Number of baths __ 'Lot size _______________ ------------------------------ Water Supply:' Public system ❑ Community system ❑'Private IN Depth To Water Table zf"�ft. NA Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑' Sandy Loam ElClay Loam ❑ Clay ❑ Adobe G' Hardpan ❑ Previous Application Made: `llfyes,dote_-f o.__) No`❑T New Construction: Yes ❑ No [a FHA/VA: Yes E] No I� "V TYPE OF INSTALLATION AND SPECIFICATIONS: \ 4 W (No septic tank or cesspoolpermitted if public sewer is available within 200 feet.) ' ~ . . _ _ __ ___ _____Sgptic T Distance from nearest well. _ ____Distance from foundation_'-_J.�� _ ----------- No. __________ No. of compartments--------- Y�_,X- Liquid de th-. ` --------._Capacity--�--- -•-'�--o Dispos I Field: Distance from nearest well---------`-----�Distance from foundation--------------------Distance to nearest lot line................. Number of lines-----------------------------------Length of each line ------------------------------Widfh of trench._-_-___________.________--. Type of filter material-------------------------Depth of filter material_______:"—---------Total length--------------..._......_-__-___________-- S age it: Distance to nearest well____-.______________Distance�ftom foundation....................Distance to nearest lot line---------........ i.�+s V, � Number of pits----------------------Lining material---------------------------------Size: Diameter-----....-: --, -_-..Depth------------._....._.....-------- � , � y � 1 Cesspool: Distance4rom nearest well__________ ___Distance from foundation.__._._..__:_______Lining material-----------------_____________-_ ❑ Size: Diameter-- F--s----------------------------Depth----------------------------- -------------------Liquid.Capacity----------------------•----gal 5 Privy: Distance from nearest!well_______________________-----___________..._-._.._Distance from nearest building-------------------.---------------------- ❑ Distance to nearest lot line------• ------------------------------------•--------- 41� Remodeling and/or repairing describe):___1c---------S=-c Kz-.,_._____�✓ �'�_�_-1- "._ ��-_----___ow � " - I- -- ___ 1 hereby certify that I have prepared this plication and that the work will bedone n acco dance with Sa Joaquin County i ordinance State laws and rules an r '' s, u d regulations of the San Joaquin Local Health-District. �.�c-� (Signed)--- -------------•-- ----•--------k---------------------(Own r and/or Contractor) By: _--------`-------------------------------•--•------------------------- ------------------------!nfle)-------------------------------------•-------------------------- (Plot plan, showing size of lot, location of sysfem'n relation to wells, buildinT§",*.etc., canlbe placed on reverse side). --bEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- = - r' -r----------------••-------------------=------•--- DATE--.------ ... REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE_------- --.--------------•--•---------------- BUILDING PERMIT ISSUED------------------------------------------------•-----------•--------------------------------------- DATE_.. Alterations and/or recommendations:----------------------------- --- -----------------------------------------------•-------------•------------------------ -••------------------------------------ ------------------------------------- -------------------------- ---_•---------•--------------------- ------•-••------------_...--•-------------•---------------------•----------- -- -------------------------------------•-----------------------.........-------------•-------------•--------•.----•----------------------- _.....-•---- •-----------•--•-•------------------------•------=---------------------- ------------------------------------------------•--•--•-----------------•--•---•--------•-----------------------------•--------------- k I -------•-- - -------- ------------------------------•-------•--------------------•-•--- •--------------------•--•---------------------------•---------------- i FINAL INSPECTION BY:. C,.Val 1 i =?' ------- . Date---- ---� -------- ---------------------- SAN JOAQUIN LOCAL'HEALTH DISTRICT 130 South American Street 300 West Oak Sireet 124 Sycamore Street 205 West 9th Street Stockton,Calif Lodi,California , may, " Manteca,California Tracy,California ES 9 REVISED B-59 2M 5-62 ATLAS