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OR OFFICE USE a 101,E -/ �"b �- -c9 _____ APPLICATION FORS NITATION PERMIT Permit No. /-_ - - -- ------------------'.'----------------------------- (Complete in Duplicate) 411 ._------------------------------------------ --- This Permit Expires 1 Year From Date Issued Date Issued ----- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work erein described. This application is made in compliance with County Ordinance No. 549. ®rf ��ISf .9,10,0 xle----•--------�. / ----��G JOB ADDRESS AND LOCATION_____,/7 �' . __I-A __ __ 4— . ....��_�,��1L-�__�_��,??-C-�----__®. ry Owners Name---- 6'? �C7 f (Flu� Phone--,V,6�"n-�?,-Z- --6 Addressi r , r� �_ / tom�7 /... Contractors Name� - --4-- I - j---+ 1-- Installation will serve: Residencepartment l4ouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ `� Number of living units: r _-- Number of bedrooms Number of baths " Lot size -------I _�f-'L�S_______________ G� Water Supply: Public system ❑ Community system Private �epth to Water Table &_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel I] Sandy Loam ❑ Clay Loam ❑ C y ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date-------------- } No ❑ New Construction: Yes UrNo ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ser is available within 200 feet.) _ Si4C x . ` - - --o----- -� Nu Septic Tank: Distance from nearest wellpQ-----Distance fro�Sfou dation__.-_`0------Material- ------ ------------------- No. of compartments- -------. -_ e 63_Liquid Ca acit 2—IR or Disposal Field: Distance from nearest well-- . . _..._Distance from foundationll9�------.Distance to nearest lot line-_a ---------- Number __ - Number of iines._p�---_. `f Q/ Length of each line _BP____ f�_:_��.�Nidth of trench.._PZ- --- -------------__-- Type of filter materia 1 _ . ___Depth of filter material-..---� _. « Total length_________________f�Q-__--_--.- Seepage P' Distance to near well--1-.00-�____---Distance from foundation_ ___._ Distance to nearest lot line__-__,.7 ------ Number of pits-__ _ --_-_-.-__Lining material_.-&. . .----.-Size: Diameter- -°-___.Depth__ l �_------______ Cesspool: Distance from nearest well--------------- from ouriclation---_-------------- Lining material--------- ---------_---------__---. ❑ Size: Diame'er- -------------± -' ------Depth-----------------------------------------------------Liquid Capacity---------- -----------------gals. f Privy: Distance from nearest well___._ --- -------------------t-_--._--_Distance„from nearest building----------------------------------------- FlDistance to nearest lot line-.-.-..---- _----._-- ` Remodeling and/or repairing (describe):--------- -------------------------------------------------------------------------•- ---------•--------------•------------------------------------•---- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------_..------_-_----------.-.____.--.__-------.._--.----- 1 I hereby certify that have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, a,`rules and regulations of the San Joaquin Local Health District. .q 2, &' YID 4t (Signed) Contractor) �>=iT10E __._._.___-_..................... .. ..... ..... ... r By:---2915 E=_MinerAve_. 'H0.6.3847i (Title}-. Y--- ------ ----- --- -- (Piot plan, showing size of lot, location of system in relation to ells, buildings, , can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - 1;7------------- DATE f4._ .-Gc +rr REVIEWEDBY--------------------------------------------- --------------------------------- --------------- ---------•--------------- ••. DATE------------------------------------------------------------ BUILDING PERMIT ISSUED---------------------- T DATE Alterations and/or recommendations:-__-. �,l� .� _ ._ ___�/� -- ------- ------ -------- • -------------------- ------- --------------- ------------------------------------------------------------------------------------------------------- -------------- - --------------------------------------------------------------------------------------- ------------------------------ ------- -- ------------------------- -------------------------------------------------------- ----- x Date------------ 8�� - . ------- FINAL INSPECTION BY:................l✓__ - SAN JOAQUIN LOCAL HEALTH DISTRICT 1641 E.Haxellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California