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0R • �vr 3A. 1// �tij__________________ �" ---"--. AF�r LIBATION FOR Si NiTA`TiQN PERMIT Permit No: __ _..5. . j ------------------------------- ---- -------------------- (Complete in Duplicate) / -Date � { ' --------- -------- This Permit Expires 1 Year From Date Issued Issued __��_ 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------- - -3--—-----�i'f, - - ",5-r ----------------------------------------------------------------------- Owner's Name--------- } --------------- ------------------------------------- ------ = - one Ph 9_ Address.................1-7-,1-2------ - -.r'•5 ' Contractor's Name--------------- ----------------------------------------------.--________-_. Installation will serve: Residence (!• Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: __i____ Number of bedrooms __Z Number of baths --- Lot size _______f70__x__-1°c�_________________-__________ Water Supply: Public:system ®" Community system ❑ Private ❑ Depth to-Water Table _______ ft. I Character of soil to a depth of 3 feet: Sand Lj Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ErHardpan ❑ Previous Application Made:; (I€yes,date---------------------) No ❑ New Construction: Yes [rte No ❑ FHA/VA: Yes.❑ No ❑ 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_ Distance from founda+ion_.-T _____.____.Mater*al---- VVAR ___---"-. ' --- U} No, of compartments___________ ------------Size__3?�_Sx-- - -.--------Liquid depth___=___Y__1-------------Capatity_.._ 0 X J� Disposal F' d: Dis+ante from nearest well Distance from foundation___t!! ----------Distance to nearest lot line---- _..-_------ W Number of lines-----------_-t---------------------Length of each line---------9d----- --------Width of french-------Z..._`_---------------------- it Type of filter material_____ -------Depth of filter material____/_r�'______________Total length---------- --.____________--_--_ Seepage P : ' Distance to nearest well------/_--------------Distance from foundation----/ __._.-.___.Distan to nearest lot line- f~_(_____- Number of pits-------_---/---------Lining material---�D.C.�f,-----Size: Diameter] ir. Depth----Z�j-------=---------- 000, I estance from nearest wll_-_____"_________Distance from foundation_______________---.Linirfg6maferia ____._.__________________ Cesspool: D ___. El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-.-----=--------------------gals. i 1 Privy: Distance from nearest well------------------------------------------------Distance from nearest building--------------------------.__-_-_.._-:-._. ❑ Distance to nearest lot line--------------------------- Remodeling ------------- --------- Remodelingand/or repairing (describe)------------------------------------------------------------------------------------------------- ------------------------------- ---- -------------------------------------------------------------------------------------•---------------------------- -------------------------------------- ---------------------------`------------------------------------------------------------------------------------------------ I hereby certify 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 rpegulations t e San Joaquin Local Health District: (Signed)-------------- =-----------__________________________________(Owner and/or Contractorl BY: --------------- ------ ----------------------------------------------------------(Title)------------------ ------- ----------- ----- ----- (Plot plan, showing size of Jot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------ ------------------------- -- --- ��A��/ ATE------REVIEWED BY------------------------------------ -------- ----------------------- ------- -------------------------------- ATE BUILDING PERMIT ISSUED-------------------------- - DATE------------------------------------------- --------------- - Alterations and/or recommendations:- I t � ,��L C-~= I ------------------------------------------------------------ ----------------------------------------------------------- j;e---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------- / ---------------------------------- - -------------------------------- ------------------------------------------------------ -------------------------------- •------------- --------------------------- ... FINAL INSPECTION BY:------------- - ------------------- ---- -------------- Date--- ----1 /------� lr SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street y 124 Syeaniore Street- .-'205' West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'S3 F.P.CO. ��`