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FOR OFFICE USE: _ fi r SJ,P ------- ------- ------- ---J ------- APPLICATION F,01;CITATION PERMIT Permit No. �� ......... --------------------------------------------------------- (Complete in Duplicate) ----.--- This Permit Expires 1 Year From Date Issued Date Issued !-..�Z.-.__--6s.SS ,. I 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 AN O AT10N___ , y -----------&l_ ----------------- ----------------- -- --------------- ------ Owner's Name_-•-- � .1 - -------------------------------------------------------------------- Phone------------------------------------ Address.----1................. f 6A9------Z'lfa... / -�------------------------------------------------ Contractor's Name---- ------------------------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence 9"0'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ______IN, ber of bedroomsQr__ Number of baths __ _ Lot size ___ ---X/dV-________________________ Water Supply: Public system Y Community system ❑ Private ❑ Depth to Water Tablet. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam ❑, Clay Loam ❑ Clay ❑ Adobe lardpan ❑ Previous Application Made: (If yes,date-------------------- No Ni, Construction: Yes ❑ NoFHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �� / I Septic Tank Distance from nearest well_-�--_ Distance from foundation_�_d---------Material---i W- _�G_��...______. [� No. of compartments______----------Size_____' ;_X_K_ Liquid, depth_�rZ_________-_:Capacity-1c � ________ Dis osal 'eld: Distance from nearest well.__P—._Distance from foundations• p ,, 1_._ .--_-Distance to nearest lot line___6�__--- # i Number of lines------------- ------------ --------Length of each line------ __-�_1 Width of trench�.Y--�----------__--1-- Type of filter materiaL_�_.Cz� �__ "Depth of filter material________�__ ____._.Total length_._-_.._ '__ _.---. fl ______ -----------//—?- : Seepage Distance to nearest well_�__._____Distance from fou dation---/A____-------Distance to nearest lot line--�_..______ ❑ Number of pits__-_X.__________.Lining ma aterial__i- <,_ Size: Diameter.Z_.�____/______Depth_`G' Cesspool: Distance from nearest well_______________ Distance from foundation--------------------Lining material__-..__.----._--_-----------_-_______ Size: Diameter--------------------------------------Depth -- I------`----- ----Liquid Capacity ---•--gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----...___________________________.____.. + ❑ Distance to nearest lot line.-.------------------------------------------------------------------------------------------------------------------------------------------- J Remodeling and/or repairing.(describe):-------- --- -------; ,0_ --------------•- ------•-- ---------------------------------------------E---------- --------•--••-•---•---•------------------------------------------------------------ -------------------------- -------------------------------- --- ------------ ---------�--- ----- ,'L F �` �{ � I -------------------------------------------l-l__=______- -A______________________.__________________---______-______.__._______________________________.____________________________.__..___.______..__________-___.._ I hereby certify that I hay, YYY ared +his application and that the work will be done in accordance with San Joaquin County ordinances,F a e s, and ruland g ' ns of the San Joaquin Local Health District.,_ (Sign(Signed)_________ _ _____ -__ _________ _ _..____. ------ ed)---- (Owner and/or Contractor) bY� �'�,`' --�- - -----------------------------Title -- - ------ - -------------- Plot lan, showing size cation of.sy� relation +O vr1s115, tfuildings, etc., canbeplaced on reverse side]. ( P e FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY....... - 's"•'- -'-- ---------------------------------------- DAT ------f ------ REVIEWEDBY------------ --------------------- ---------------------- DATE----------------------- -----------------------•------------ BUILDING PERMIT ISSUED-------------------------------------------------------- ---------- ------------- DATE------------------------ ------------- r ------------- Aiterations,and or recommendations:___.___._ ._ J ------- ----------------- 4>-- ___- -- - , 1 -- :------- -- f ~C ----------------------------- ---rte--`-------------------�--- -- -- .-f``c. f _rz_Pre FINAL INSPECTION BY:.._ .-- `� '�----------------------------------------------- ---------- ' -µ -.--- --------- - -------------------------- -------- -- Date------'------=--''--- --�_�----------- ------- ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.ffaielton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,Callfornla Lodi,California Manteca,California .. Tracy,California 1 ES 9 REVISED 8-59 3M 3••63 F.P.C4.