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Permit No. APPLICATION FOR SA57 NITATION PERMI l V(Complete in Duplicate Date Issued -_-- -----y/ ibe . 3 45, Application is hereby made to the San Joaquin Local Health Distr-sc 549 a permit to construct and install the wdrk herein descr This application is made m compliance with County Ordinance No. --- Hiak= _aha-------------------------------------------- -4535- JOB ADDRESS AND LOCATION ----------------1�3- --- ---- --_- Phone-_5 - ---------------- .------ -----------------------------------•- Owner's Name----------- •--•Qrv--131e_-�v_E1 $- -------------•-----•----------•-- ,g -I(� . '--:-•--------------- Phone------3:73955..-..------- Address------- --------------- 1 a Contractor's Name--------- �" Trailer Court ❑ Motel ❑ Other ❑ i Apartment House ❑ Commercial ❑ Installation wily serve: Residence ® ; P I Number of living units: _l.__�Number of bedrooms -1-_-- Number of baths ._�._ _ Lot size ._-. ;�---�.�-- ----------- - } N s ` tCommunity system ❑ private ❑ Depth to Water Table �}-- f}- Water Supply: Public system ® Clay Loam l;] Clay ❑ Adobe[ , Hardpan ❑ Gravel ❑ Sandy Loam ❑ Y Character of to a depth of 3 feet: San ❑ No No ❑G New Construction: Yes ❑_ s Previous Application Made: Yes ❑ ' R TYPE OF INSTALLATION AND SPECIFICATIONS: 1} (No septic tank or cesspool permitted;if public sewer is available within 200-feet.) ` t r Septic Tank: Distance from nearest well----------------- from #oundati�q�id depih__Material-.------_Capacity ....... ..... '-..-_-- No. of compartments--- - - -- ---- -- ---Size $KITING Distance to nearest lot-1 ine--- ---------- Width of trench----------------------------------- Disposal --- -- --- -- ----- Disposal Field: Distance from nearest well----------------- from foundation ion--.-_-- ----- } L ING �{Nnberr o'i lines--- ----------F-------- Length of each line - - r _:_De Depth of filter material----------------------Total length_------- ----- Type °;Rfilter rnateraal..___------- p _--_Distance from foundation-_-1Q._____.---.Dis�ance to nearest lot ine_-._.,,�----- --- Seepages Pit Di`stanceto nea est w II_;_"_I1S1-___"-- -- --. De tn........off-f--------------- -- Number a `pits.__-_ -. -----Lining material__. lx �C ----size: Diameter__.._ p ® Distance from nearest well----------------- from foundation--- - ------Liquid eCapacity- `----------------gals. Cesspool: --- .D -------- F - _V-�, Sife'. {6iameter--------------- ...... p Distance from nearest building--------------�� }„ ,� , -_ - Priv Distan e fr°m.nearest well - i n Distance to nearest tot line.----- -- ----------- ,., '-- a--- # F---------------------- Remodeling and/or repairing (descnbe): e.T� -. -------- - -- -- ---•...r.e-------------- ------- "--------- ----------- �.., T= - ;", t Ii '��y ---------------------- ------- ----------- -------------------------" •- ----- 't!- application and thYthe work will be done in accordance with San Joaquin County I hereby certify that;;1 have prepared this;app ordinances, State laws, and rules and'regulations of the San Joaqujn Local Health District. ,. - t _ weer and/or Contract �_.. {0 ar {Signed) ? � a-M_ _ �-- -------------------- --------- Title - Get1. }ExX".•. ---------- t ! { 0 ----------- BY:--------------- -------- - � _ _. � buildings, etc., can be placed on reverse side). „ {plot plan, showing size of lot, location of systm in relation to weVls, FOR DEPARTMENT USE ONLY 1 -- --a--k I DATE----�-� ---- APPLICATION ACCEPTED BY---------- y� --=- =__ - - -- -- ---•-.DATE = "'== --• ED BY! r" .. ----------- DATE---------------•--------------------------------------------- ----------- Alterations6+PERMVT ISSUED-.. ---- - ----------- ancf%or�recommendations:.., -- --•---- -----•---------------- - ------ -------------•--- - "`: =_ ------ ---- - ---------------------4.-'-----------•__.-..--.-.......--.-._.. --------------- - ----------------------------- -------------- -------.. ---------- --------------.._.-.--..--. ------------------------------------------------ ------ - ---- - ------------ . r -. Date-- --- -- ----- ---` ---- FINAL INSPECTION BY:--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 814 North "C" Street 0 Wast oak Street 132 Sycamore Street Tracy, California 30 130 South American Street Loai, California Manteca, California Stockton, California �e o—,)KA in-s2 Revised W-2100 __