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FOR OFFICE USE: , , _" 4NITATION -------------------:--------- --------------------------- APPLICATION FORS PERMIT Permit No. ._Z2_2._6.__ ---------------- ---------- - -------- -- (Complete in Duplicate) --------- -- This Permit Expires ] Year From Date Issued Date Issued i Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application ismade n c�o�hiance wi# county Ordinance No. 549. JOB ADDRESS AND LOCATION --------------•------ -Yr �r 7z f� C Owner's Name = ~ "-----•----- ----------------- - -- ------------------------------ Phone ----------------- .:.---------- Address----------- D ^�' -� k = _ - _ Contractor's Name------------ __4 4__ ° -••--------- Installation will serve: Residence Apartment House ❑/Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units;.---7"/umber of bedrooms __1r Number of baths _1 Lot'size - Water Supply: Public system ❑ Community system ❑ Private x Depth to Water Table 71,- ft. (� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Cla ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date-------------------- No New Construction: Yes No FHA,VA: Yes Nox TYPE OF INSTALLATION AND SPECIFICATIONS.• (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p ,,w Distance from nearest well_________________Distance from foundation----.---------------Material -____.._______-____...________._____f___..____. s .: ." No. of compartments Size Liquid depth - Capacity ----------- Disposal Fielc(: Distance from nearest well----J.r.A___Distance from foundation___A_:�----------Distance to nearest lot lips---J ------ tn �] ' .p&. Number-of lines----- ,'- --------------- Lenghof each line/-�: {. Width of french-----^_��____.____-: l : :-Total length -------------- ----------j �Depth.of.Type.of�fl#er mat' filter materal__ ! eepage Pit: Distance to nearest well------------___.-----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-------------- -----------9ai(Pp A. - PrivyPrivy:' Distance.;from nearest well___---------------------------______________________Distance from nearest building 17- . 7 1 ❑ Distance to nearest,lot line------------------------------------------------------------------------------------------------------------ 4 Remodeling and/or repairing (describe:________________ i f ___________________________________________________________________________________________ _______________ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordi nces State laws, and rules and ,regulations of the San Joaquin Local Health District. (Sig -------- - -----=33-------------- ---------------------- -( caner and/or Contractor) Sy. --------------------------------------------- ---------- :-(Title) - -------------- - ---..._... -------- (Plot plan, showing size of lot, location`of system in relation,to wells, 6uildings;'etc., can be placed on reverse.side). ;a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ------J-i------------------------------------------- ---------------------------------------- DATE REVIEWED BY----------------------------------------- BUILDING ------------------------- -------------BUILDING PERMIT ISSUED--------------------=--------------- ---------- - -- -- - ---------- DATE---------------.,-------- -------- i Alterations and/or recommendations:----------------------------------------------- ------------- --------------------------•-•------------ •---•-------------••------ --------------- ------------------ ---------------------------------• ---------------------:---------------:---------------------------------------------- ----•-------•---•--- -------------------------------------••--------------- 3 r ---------------------- --------------------------------- k --------------------------------- --- ------ ------------------- - _ ---------------- _ FINAL INSPECTION BY:,---------------- f - Date----------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 1501 E.Haselton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California i Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 3M 3-'63 F.P.Ca.