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1 J7 _—a��aww�s—a__ e-rwr..m•r�^�rr-. /ff 111 APPLICATION FOR NITATION PERMIT Permit No. %? (Complete in Duplicate) T..."_""' _ .. bate Issued ._�/o• " Application is hereby made to the San}Joaquin Local Health District for a permit to construct-and install the work herein described. This application is made in compliance with County Ordinance No. 549. -JOB ADDRESS LOCATION_._Z�""2_Q Owner's Name ' R -----------------------------•_-----------------------------• ---- ' r ,,�• __ ___________________ jJ ---------- Phone-,4 j. . -L- - t Contractor's .Nam Q ,l,,, � - - ----------- -----= .Phone. �.- Installation will serve: , Residence ,�,�'� t --- � hd' flpartmen+ House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _4____ Number of bedrooms ---Z- Number of baths ---1--- Lot size �'°o •�f / Water Supply: Public system' ----------------------------------------- pP y isYstern Commun'ity ❑ Private ❑ "Depth to Water Table_ Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sand Loam , Y ❑ Clay Loam ❑ Clay ❑ Adobe "-Hardpan ❑ Previous Application Made: Yes ❑ No r [ rNew, Construction: Yes Q�No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic .tank or'cesspool perrnifted if public sewer is available.within 200 fee+.) } Septic Tarlk: Distance<from nearest well_________________Distance from foundation.------------------ ��l S !� Material `-------------------•------- ---•-- No.,o£compartments---------- ------Size------ •-------Liquid depth- Capacity � . . Disposal Field Distance from nearest well..._...............Distance from foundation__________________ Distance to'nearest lot line_____________"-_ rNumber of lines-----------------------------------Length of eac7b line---:-------------------------- Type.of filter'material------------------------ Width of trench_------------__"" Depth of,filter material---------------------'`Total °length------------------------------------------ Seepage V number of-•. r ..a " " -:- i.-..i. � 1 Pit. Distance to ne'ares�t well__!.UX mDistance from foundation___!_Q_______..... Number Disfece to nearest lot line-______•_""""-"" Pits -------- ---- aterial---b-4.�� Size: Diameter �' _ " -DePtn •Q 6 - Cesspool: 'Distance from nearest weii______-______ _Distance from foundation--------------------- material_._--"-..---------------------------- ------------ ----- ----_-----_-r__-__----- ❑ Size: Diameter+ = - Depth ------ f ----- -----------------Liquid Capacity gals. rrvY: " Distance from nearest well___.__----_-------------- - -----_---- Distance from nearest building `L ' Distance:to nearest lot line- -----------------I--------------I-------- -- ---------------------------------- Remodeling ______Remodeling and/or repairing (describe): _ }\.t��1 � �- " --------------------------•-------- - ----------------------- ----------------------- "' _ �, ------ _ = ---------------------------------------------------------------------------------------------------------------------------------- -------------------- "I hereby certify +hat I have prepared thin application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and`regulations of the San Joaquin Local Health District. y (Signed)------ 1 -------------- - ----- --------------------------------------- ------------------------------------- ---------------------------------- By:--- M (Owner / on+raef and or C or) ---- - °'c�--- -------------------------------------------------------------(Title]--- J�reu �- {Plot plan, showing size of f, Iota+ion of system in relation to wells, buildings, etc.. can 6e placed on reverse e);' 3 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_______._--------- ------------- ---- ------- -__---------- __ _ d REVIEWED BY--=------.--"r = - --- --- -------------- ------------ DATE------ --------•-- BUILDING PERMIT ISSUED_. - -- DATE-- BUILDING - Alterations and/or recommendations:___"_"--,"---_ ."- I � - = DATE _ � f_/ �-- ---------------------------------•-------------------------------- ----- -------- --- ---------- /_7 �.--Sim - 7A '. .P f� �f f�Q ' ! -- -- _fir�� iii ��-•--- --- -s� -----.T�_ 'd� ,vim �r WimAI . fQ,P1 -------- or _ _ � :--- _ c. F - - ------P--Tr_Z0_,tea.......J _G...... r �� r -------------- �. FINAL INSPECTION BY:_ _ '__- `# i r --=--- -- - Date-=---- ------ -- J , SAN JOAQUIN LOCAI_'HEALTH DISTRICT 130 South American Street 300 Wes} Oak Stree} r - r f32 Sycamore S+rest $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Reviseci 1-57 i'.P.CO.