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FOR OFFICE U 3 -}, APPLICATION FOR S*t4t ATION PERMIT Permit No. --------------------------------------------------- (Complete in Duplicate) ---------------------------------- This Permit Expires 1 Year From Date Issued Date Issued _.... _.__ d 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 LOCATION __ �� . �/�9---- --•- - - ----�------,----lam -------- ---- ---- Owner's Name 61 Name ---- ------------------------- Phone C Address -•--•--•--------------------------------•-------------------- -------------.._....--•--....------------------------------------._.. Contractor's Name...----- ------------------------ ------------------ ----------------- Phone Installation will serve: Residence ®-`Xpartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ CSIIt[11bPr_nf..liuir +_units __-�_ - Number_of-bedrooms Number of baths _1-__- Lot size ...>'?.4-X------ 1------------- Water Supply: Public system ❑ Community system private ❑ Depth to Water Table _ ft. �:naratlerbrsil��Tv-�ae�trrrS� tel�r: 'aadJ-Lj `�=d4F'u raar{uyl cvm,f Lj Previous Application Made: (if yes,date--------------------) No V� New Construction: Yes g?"'No ❑ FHA/VA: Yes Z3-1 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----/A*7_...____.Material--- .............. No. of compartments---- � ,--------------Size ��p------- - 01 l Disposal.Field: Distance from neares well.--_—__._-Distance from foundation..../10.........Distance to nearest lot line......... \ ®/ Number of lines.__ ---.-----� ___,_y Length of each line----�.�.-- -_ Width of trench.._A_------------------------- ---------- Q Type of filter material./,,, - �f�-Depth of filter material--- ---------Total length...��,�------------------------- \ Seepag�kit: Distance to nearest well_-.�-------------Distance f1pm feclation___��____.__.,ji5fance to nearest lot line_�1_._._ [+� Number of pits_-.-.A-_.--.------Lining material--, Q. /�.-Size: Diameter�J,?______________Depth____��._____......____... Cesspool: Distance from nearest well-----------------Distance from foundation_-----------------Lining material--___-_-__-___----__-_--_.--_-.___. ❑ Size: Diameter--------------------------------------Depth_---------------------------------------------------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well------ ----Distance from nearest building_________.______________-_-__---------._. 0 Distance to nearest lot line--------- --•------------------------------------------------------------ ------••------------•-----•-----------------•-------------------- Remodeling and/or repairing (describe)-------------------- ,�Gr -••------•--•------• •--•--------•-•---------------..:..---• - ----------------•-••-----.-----------------------------------------•---•----•-•----•-•-------------•-••-------•-•----•-----•-•---------•------------------I----- ---- - t I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) ---._._---. or Contractor By:----------------------.............................. --------------- �_ e4 [title) ,� l- '`vis (Plot plan, showing size of lot, location of system in ,tion +o wells, buildings, etc., can be placed on reverse side). FOR DEPART NT USE ONLY / APPLICATION ACCEPTED B - ----- ----- ------------------------ DATE_. -------------------- REVIEWEDBY------- ----------------•--•------------------ /---------------------- --------------- ---•------------------------ DATE------------------------------------------------------------ BUILDING PERMIT ISSUED------------- / - ---------•----------------- DATI------------------------------ and/or recommendations:__ .__ ._- �/� ,,� _�, _ i�o-B...0--••--- .--_--- - ------------- � � �/ •- �, - -ice- �:---------- ----------------------------------------- ----------- --- ------------ ---- 17 FINAL INSPECTION --- --- - ----- ---• -- - -- -- - . .- SAN J QUIN LOC HEALTH DISTRICT 130 South American Street 300 Writ Oak Street 184 Sycamore Street 805 Wort 9Th Street Stockton,California Locil,California Manteca,Caflfomla Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS