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FOR OFFICE USE: ---------------------- ------------_--11- ------- APPLICATION FOR,�17ATION PERMIT Permit No. ----------------------------------------- ------ (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 instal e work herein des/ribed. This application is made in compliance ,with County Ordinance • o. 549. JOS ADDRESS AND LOCATION_ leSX_ �_ __ - _ _ Owner's Name. -/ 2-LC-- � lr "/C =L ------L ---- ---- ------)_ Phone- ------- Address. = a... "� -� Contractor's Name -- - &C,-41 C,-41 Z------------- ------- Phone----------------------------------- --------------------------------------------- Installation will serve: Residence ©moi pertment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livin units: _.__f_ Number of bedrooms _ �- g ..�._ Number of baths __-_____ Lot size .�"r'�___��.__�_�__�_��_____________ Water Supply: Public system ❑ Community system ❑ Private epth to Water Tablee-7ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ID--rTa,_rdpan F] Previous Application Made: {If yes,date--------------------) No ❑/" New Construction: Yes jo ❑ FHA/VA: YesC�Nlo El,L) TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` . Septic Ta • Distance from nearest wej)_,. --_-____Distance from foundation___f_C�__�____.Material.._.__P�"P_-_.C 9" - _ _` No. of compartments_...__',-___._..-----------Size__-1',X __ _ / j__Liquid depth___ _l_ Capacity_ " Disposalield: 4 i Distance from nearest well-_. ---_...Distance from foundation___ _.-__....Distance to nearest lot )---__- 0 ; Number of lines-------- ----- ' ------1�----- Length of each line----- '_ Width of trench--- --------------------- i Type of filter material___.__ __- of fifer material_-�_,�__/_____-Total length____�/!� �I-.___- Seepage .it:' Distance to nearest well----Aftly----Distance .� foundation___�_0_-______.D��nce to nearest lot line c Humber of its.___ Lining material__ C?�i -Size: Diameter___.__-.-_.-___.Depth_ _ ___✓ __--_ Number Cesspool: Distance from nearest well-----------------Distance from foundation------------0_......Lining material------------------------------------ 1 ❑ Size: Diameter--------------------- ----------------Depth--------------:------------------------------------Liquid Capacity----------------------------gals. Privy Distance from nearest well------------------------------------------____ _Distance from nearest building.----------_____--___-________--__-.__._. ❑ Distance to nearest lot line----------------------------------------- -` ;• j ----- f - - -------------- Remodeling and/or repairing describe :----------------_ ---------___ �--��Y ___mac- _ - --------------- -------- ------- -----------------------------------------------------------•----------------------------------------------------------------------------------------------------------------------------------------- - - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ' ordinancese laws, and ule andrts of the San Joaquin Local Health District. Si ned �W_D_` --------------------------- (Owner and/or Contractor) [ g ) Q ' f ------------ Title el�e--_.' './ By: r ( )-- ------ (Plot plan, showing size oflo ,`location of system in relation to wells, buildings, etc., can be placed on revel a si e. r i I FOR DEPARTMENT USE ONLY L APPLICATION ACCEPTED BY-------- ''--------------------------------- ---------- DATE------ - y1` 0 REVIEWED BY-------------------------------- ------------------------------------------- DATE----------------------• ---- i • BUILDING PERMIT ISSUED----------------- ------ '----- --- ---------------`-- ) - ----- ----------------- DATE------------------------------------------------------- --- Alterations and/or recommendations:-_-____-_-; '~' I I I 1 - --------------------------------------------------------------------- k--------------------------------------------------- ---------------- -------- --- --------------------------------------------------------- - FINAL INSPECTION BY:- ----- ----------- Date--- /---�- ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601'E:Hasiellon Ave. 300 West Oak Street 124 Sycamore Street 4 205 West 9th Street *Stockton,California Lodi,California Manteca;California y }` \ Tracy,California ; F.P.0 Q.