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APPS. ATI NITATION PERMIT Permit No. ,� 9 1 - �' (C iic�±e1 Date Issued --__--_ -11-'--• Application is hereby made to the San Joaquin Local Health Di ct~f or ap mit to construct and install the work herein described. This application is made in compliance with County Ord' ane No. 49. JOBADDRESS AND CAT ON.._• -/_ D ` ------ --- ------------------- ----------•- ---------------------------------------------�----------------------------- Owner's Name - -•- --- - ------ ------------- -- --------------------------------- Phone—A—----------- ------1 Address------ 7Z = ----------------------------------------------------- - Contractor's Name------------------------ -- ------------------------------------------------------ Phone,l " Q ------------------ --- ----- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trail-r, ou t ❑ Motel ❑ Other Number of living units: ________ Number of bedrooms -------- Number of baths_____ Lot size _____ '_-__ ..T--_____________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table/:5__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobK Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No &r FNA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPEChFICATIONS: (No septic tank or'cesspool permitted ifublic sewer is available within 200 feet.) Septic T k: Distance from nearest well{__ �� _ `�/ e e 9�� p Qistance fro fa ndation-/-- Magri�l f No. of compartments________------------Size... 5-------------Liquid depth___4_iti-.-----------Capacity..,! Disposal F' Id: Distance from nearer well ll Qom_Distance from foundation +4.1_____Distance to nearest lot lin,___ -�_-_- Number of lines------ -- Length of each line--_//__-_____-___--________Width of french---- --Length -__--______________ ----- - -- - Type of filter material f___ ------ Depth of filter material-_��_.__________Total length_-___/-r1V-----------_--------- Seepage Pit: Distance to nearest wel#----------------------Distance from foundation....................Distance to nearest lot line------_-.--_----. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------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------------------------------------- . ❑ Distance to nearest'lot'fire------------------- --------------------- t---------------------------- ------------------------------------------------------- Remodeling and/or repairing (describe)-------------------------------- = --__--------------------------°------I------------------------------------------ ----------------- ---------•---_ _ 1 , ------------------------------------- --------y_.» f ------------------------------------------- -----------------------------•---------------.....---•-------------------------------------------------------------------•-----•------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law , and rules and regulations of the San Joaquin Local Health District. (Signed) ..�. ------ '--------------------- --------------- - e -------------- - - --- ••----------=--- --- --- ------------- -s- ._ rand/or Contractor( By: (Title)_ Y:----------- C � 4relaflion'to .� -rw (Plot plan, showing size of lot, location of system ' wells b6u:ildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- ': DATE „ REVIEWED BY-----------------•--------------- _ - i �2� { 'f ��`� DATE ---- 4 `-a r � � - BUILDING PERMIT.ISSUED------------------ --------�-------~" --------------- - ---- -- DATE - f Alterations and/or recommendations:..- -- -._.-- ------- -- �f._ ----------------------•--•-------------------------------•----------------------------------•------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- -------------------------------------•----------------- FINAL INSPECTION BY:. �lr-- _ - bate sem' L� J..`"_ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revises 3-57 F.P.CO.