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FOR OFF.ICE�USE: k APPLICATION fOANITAiION PERMIT Permit No. . --------------------------- -- --------------------- -- (Complete in Duplicate) � This Permit Ex ires 1 Year From Date Issued Date Issued 1d..� ' Application is'Nie eby'ri-ad"e"to"the-San Joaqu'in'Local Health District for a permit to construct and install the work herein described: This application is made in compliance with Count Ordinance No. 549. `f PP P Y JOB ADDRESS AND LOTION_%1't/1�ICr� '.----`-tel--I f��''° -N. ':/ --D /rlS,y l - -{`-```�-------------------"•- _... _` =J--------------------------- Phone------------------------------------ Address Name----------- -- --------- --- ---- � � ---- -�� ------• -- Address % -' el -----------• .��:7x ''--------•------------ -------------------------------------•-------- '.-- Phone_- r f 7------ I Contractor's Name__-_--_�� Installation will serve: {Residence P]""Apartment House I] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:.---/--- Number of bedrom's Number of baths -.)-_ Lot size "----------------------------- Wafeir Supply: Public system ❑ Community system ❑ Private ID Depth to Water Table _,6 oft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam M Clay ❑ Adobe❑ Hardpan ❑ - Previous Application Made: (If yes,date--------------- ----) No Ed. "New Construction: Yes ®1No ❑ FHA/VA: Yes ❑ No 1�` TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if public sewer is available within 200 feet.) s Septic Tank: Distance from nearest well_/�O--- Distance from foundation__ ____________________ ©� No. of compartments_._____ -----------Size_&AA� X(- --------Liquid depth_ _ . __--__ Capacity_' a.__ � I . f 1 Disposal ield� Distance from nearest well./ --..-Distance from foundation -_ ,2_ ___.____-Distance to s earest lot line______ ❑ Number of lines--------`----- -------------Length of each line-- ---: -7d----,Width of trench__. - '�------------------ V) Type of filter material__ / L _.Depth of filter materiaL/er-✓r_.._____Total length_a___«'�"l__-____________----------- Seepage Fif., Distance to nearest well___,,.Q1.2--._._Distance fr found tion___,�(,P___,___.Distance to nearest lot line___- © Number of pits--- -- = r`�_5 --------------L "rDthL � I Cesspool.: Distance from nearest well--------------___Distance from foundation-------------- . Lining materifaL...............____.__A._--_-_--___r-� Size Diameter- ---------- -------------- -..Depth------._`--- ----- - Liquid Capacity - gals. i Privy❑ Distanceafsom nearest well_.___ �.__ -- -... _. _._. ._Distance from nearest building____ __________________ ________ _ :, _ ., ❑ Distance to nearest lot line__-- I 1 Remodeling+and/or repairing (deicribe�:---�/// �J' == `"` '° - ------------------- ke --�'t-- -------- ------ ----------------- ------------------ -- --------------------- ------------ ' ---------------=N----- ----------------------±----- -------------------------------------------------------------------------------------------- -- ------------------- -------------------- -------------- - ------ i------------ ------- - ------------------------- - - I hereby certify that I have preparedJhis:application-and_that_.the-work will be done in accordance with San Joaquin County ordinances, State laws, and rules a�egulations of the San Jo(e Local Health District. F - _ f��5--- _ -- -_____---_ w and/or Contractor) I {Signed} '�._ _ 1 $ �� -- ton of system in relation to !ells (Title) �.:�__ - ---- - -------------- _; --- ---- -- {Piot plan, shbwing size lot, I Tdt on t y I , buildings, etc., can be pl�ed an reverse side). v �r+►�� «_ -a !_._.FOR DEPARTPENT USE ONLY j 3 APPLICATION ACCEPTED'Y_________________ DATE. . z�`-I---G 11>---------------------- ----------1Y--------------------------- DATE. i - ----- --------- BUILDING PERMIT ISSUED------ ------------------------ ---- ------------------- - DATE . I = .,,. and/or recommendations "'""% / —�..._� .�3 - ----------- -------------------------------------- Alterations -----------------------------------------------------------= ----------------------`-------------- -- - --------------------------------------------------------------------------------------------------•----------. - w ------------------------------------------------------ --•--------------"---------------•---------- I ----------------------•----------------------------------------- --------- '= - -- --': -----------�-•------------------------------------------------------------------------------- -"----------------------------- 4 _-__...._ ----- --------------------- ------- - ---------------------------------------------------------------------- — — ----- ..__...------------------------------------------- --------- ------------ � S ' BY: Date--------/1 -----, /��----------- ----- ---------------- FINAL INSPECTION BY:_..__ .-____ C/ SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E.Ha:ellon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California - r �