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4. APPLICATION FOR SA NITATION PERMIT Permit No. -��,��__•; r (Complete in Duplicated DataIssued �� Application is hereby made to the San-Joaquin Local Health District for permit to construct and install the work herein described. This application is made in compliance th C(.QiLnfy Ordinance No. 549• ` JOB ADDRESS AND LOCATION.- . ----------- ----- ------b-x t------- _ .......... ----------------.----------------------------------------- Owner's Name_--��"frlrl..t___ ;;--, -------------------------------- �----- --- -. Phone---------•--- ---••-=-- -------•- F w .m._ Address------------ -�-:��-- -�- -------�• - --------- - -- -- -----------------�-- � .�.. •------------------------- Contractor's Name ------ ---•--- Phone Installation will serve: Residence Apartment House ❑ -1Commercial I ; ❑ . ❑ Number of livin ❑ Trailer Court Motel ❑. -Other g units: - ---__ Number of bedrooms -9— Number of baths s_{{---- Lot size _ F !' „ ."--------------------------- Water Supply: Public system ❑ Communify'system ❑f• Private K Depth to Water T,able �56. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe J Hardpani❑ Previous Application Made: Yes ❑ No K New Construction: Yesi4, No ❑ FHA/VA: Yes ❑ No-g. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200.feet.) Septic Tank: Distance from nearest well_- '10-_---Distance from foundation_10-----------Material--.--- "- _ --- No. of compartments------------aZ--------Size-.- - Capacit = -� -.-..Liquid depth--------------- {` Disposal Field: Distance from nearest well_ Distance from foundation---- - --."-------Distance to nearest lot line_ 4 Number of lines----�---_- ..-__Len ----------- Length E " 9 ---- --- g of each line-•---- -- --------------Width of trench----.I-- __ Type of filter material-- // "" filter material--__1-g --.-____---Total length_- 1. 1__------- ----------••----- Seepage Pit: Distance to nearest ------Total from foundation-----------"�_-=_.Distance to nearest lot line---_--_-.-,-_---_ ❑ Number of pits-------------- -------Liningr`material--------?--------------Size: Diameter------------------ ----Depth------------------•- --- Cesspool: Distance from nearest well--------------- Distance from foundation_-----------------Lining material_-.__------------_-.--:-__. ❑ Size: Diameter------ --------------------------------Depth'.---------- Capacity - --• ----= ----------- ------------= --Liquid Capacity---------�------------------gals. Privy: Distance from nearest weli.-.------- ------------------------ --- --Distance from nearest building ❑ Distance to nearest lot line----�---- ----------- � , ----------------------------------=--------------- Remodeling and/or repairing (describe)::--- __ -------------------- -•----------------------- - -----------•------------ ----- r. -----•----- ------•------------------•--- -- -------------------------- °------=---------------------------------------------------------------- i-----=------------------------•-------------------------------- - 1 hereby cerfify.that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San 'Joaquin Local Health District. Y t (Signed). --------- ' . L --:----------------------------------------------- Owner and/or Contractor) { ' By:------------------------------------------------1:....-----... ------------------------------------------ - -- Title------------------------------------------------------------------ (Plot plan, showing size of lot, location sof system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ -- ------ DATE------- ------ lEWED BY ------- ------------ -- ------------ DATE---------- ------- BUILDING PERMIT ISSUED-------------------- Alterations ------------ ------Alterations and/or recommendations: ----------- ---- ---- ---- ------------------------------------ ----- ------------- ------------- DATE------- - ---- ------------------------------ "-` -- ---r'-----'.---t ---- �-----0--- ------ - ------ --------------• ---------- -- ---------- .. ---�-1------ --------------•-------r�------ -- -+.-..-.-_-_+ /-� ------ - - - • ---- ------------- ----------- 1377 ------- / ---------------- ------------•-----------------.-------•--------------------- --------------------------------------------------------------- -------- ---- - ------------------------------------------------- _ FINAL INSPECTION BY:-___----.p ------ Date----- -- -- ✓ - :"-- _ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street _ 3 0 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21x1 , Revised 1-57 F.P,CO.