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.FOR1OFFFICE USE: Jf._�-_ f. -: Permit No. - APPLICATION FOR rSA.NITATION PERMIT - - ----- - (Complete in Duplite] Date Issued _1�_� _ _--_ This Permit Expires 1 Year From Date Issued A lication is hereby made to the San Joaquin Local O Jena{ pp h District for a permit to construct and install the work herein described. This application is made m mpliance with Coun.y, nce No. 549. �� '3.- t Tz79 _U.� : /'�v�_ 57`v vv7a.v --- - S. _ �hf/la� �r /V+� --- -----�--------•---•- JOB ADDRESS AND LOCATION---------------- -- M --3 , ---- Phone.. ------------------------ 'Z -) ------ --- - ------------------ Owner's Name------ _ N �HZ�----•---��-_' Address 5� '_../!✓/ f?p. ! -- � a -A__ � �-------------- h --------------------------_------------------•--�. C� 7-1 ,. ---- l s ... ./,c=7�----------�=. e�,��----~'-�=i.�e1/.ems----- --------------------------=- Phone 5�(�� I Contractors,dame,-- -------_---------�------ f 4 "Installation will serve: Residence �,:�Apartment House ❑ }Commercial ❑, .Trailer Court ❑ Motel ;;'.Other ❑ 3 ------- Number of livor dnits: ---.--__ Number of bedrooms _- Number of baths =_'`.Lot size _-._-f -X- g dD-- ft. Water Supply: Public system F1Community system ❑ Privaite Depth to Water Table? I Character of sail to a depth of Meet: Sand ❑ Gravel ❑ Sapdy Loam ❑ Clay Loam ❑ Clay E] Adobe Hardpan ❑ F Previous Application Made: (If yes,dcste.----------k--- ) Nojg New Constructon:,^YesX No ❑ FHA/VA: Yes ❑ Na [1 TYPE OF INSTALLATION AND ESPECIFICATIONS: ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I I 4 /D �6 Septic Tank:'',._ Distance from nearest welly- Distance from foundation__.------- "--.----.Material. -- ---------- ------ - D 0 �/'-t`. • a --------Capacity--•----'�------- r Nd. 'offcompartments-----------.x ii - -Size-,; X� tlrX % ----L quid depth--:-.- ]l . • yam, �. `�•' _ -- ` I 1 {_ ��-__._. 1 Disposal.Field-_' Distance from. nearest well--;-7 --.-Distance from foundation-__-lQ-f-.......Distance to nearest lot Line----------------- Len th of each line 7 -------------Width of trench.-_�5Z---------------------- Number ------; ------------- rV Number of lines----_--_-- g - --------Depth length----------------��----.----- of filter material-____- p See a e Pit: Distance t .j r /U '�� •^_.�' � ) g � -- - 'n______________•----.D�stance to nearest l�liner---------_---- p g o'nea`rest well.-.�----------------Distance from foundation------------------- Seepage Diameter------33"-----De th----.----3 -------' -° ' f ® Number of pits--------- ------------- well Linin material- from ou dat o Linin material------- ---------------------------- Cesspool: a~ Distance from nearest _-Li-Liquid Capacity gals. ❑ Size: Diameter------ ---------- -----=--------------Dep'th--------------------------------- q p Y - Privy: e Distance from nearest well------------------------------------------------ ----------- -- Distance from nearest building------:-_-- ----------------- " 1. ❑ Distance to nearest lot line--------------------- - --I-----' ----- ------------------------ -------- ------. Remodeling and/or repairing (describe) = ' ---------------------------------- ----- ------------------------------- -------------------- ---------------------------- ---------- -�-' ----•---------------------------------------------------------------- V s; -------------------------------------------- -•------------------------------- . I hereby certify that 1 have prepared this application and that the work will{be done in accordance with+San Joaquin .County ordinances, State laws, and rules and regulations af..the San Joaquin Local Health District. i ------- Owner and/or Contractor( (Signed)- r. R ------------ ------------- - -- ---- - ------- - ---- -------- ----------- ---- - :.�-- ---- _ -- -- `[Title)- i By:---------- --- - -- ----' --- ----- (Plot plan, showing size of lot, ati s em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- I� GI//� DATE.--- ----- %� G �-- _ DATE------------------------------------------ ---------------- REVIEWEDBY--------------------------------- ----------- -------------------------------- ------------------ BUILDING PERMIT ISSUED--------------------------------- -•---------- --------- DATE te a#ions an�/or recommendations:...- -- ----------------- -- ------------------------ ---------•-------- ----- ' - --------------- -- -- ------ ---------- -----=-------------------------------------------------------------- ! : -----•-------------------------------------------------------- ------ -----------------------I-------- --------------- ---------- ------------------------ - - --- �� S' ------- I Date------------------- ----- .lir C/,��.. ---------- ----- -------------------- - - FINAL INSPECTION BY----------------- k, 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Ha:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ? 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