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FOROFFICE USE: b �- y---�- - ------------- -- --- , {�N� �r (Ail / --- _ APPLICATION FOW�SAMYATION -PERMIT Permit No. �----•---- c( ----- ? i I (Complete in Duplicate) ----------------------------------------- --------- This Permit Ex ires 1 Year From Date Issued Data Issued 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. 49. - —. - p JOB ADDRESS AND LO ATlON__�..._...____"- Qo ----er ----------- - Owner s Name t 1,55 _. _C�_ _ I. % _ ..i � — �p - - L(YL't2_ _ `y Phone - - Address----------------�,��r��,�-•--Q`s3� ��_ ,� .---- ` ,/ . IVl ---------- -•-------•----........... Contractor's Name--------------- ,� s d ------- Installation .yr Phone ...• will serve: Residence ` ' • ❑: Apartment House ❑ Commaeia'l ($( Trailer Court ❑ Motel ❑ Other ❑ I Number of living units:'------ Number of bedrooms:{`_ Number of baths, Lot size ..............-- ' •-•-•--•-••----••---•---•---...__.. Water Supply: Public system `Community system•"❑ Priva`to ❑/Depth TO Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ravef d Loam t ., ,� �, ❑ Sanfy. ❑� Clay Loam ❑ Clay C] Adobe Hardpan (3Previous Application Made: {If yes,clate'__-___._-._'------) No"� .-New Construction: YesA No ❑ FHA/VA: Yes ❑ ?No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public`ewer.is available within 200 feet.) Septic Tank: Distance from nearest well sr �__-_-Distance from foundation. __ �2 �UDO� -Materia!_ .......__.. No. of compartments-------- _--------..:5ize_� -- - - q�_ - /�-!---- E ' r. '- . r - - f _s_Li uid _#h_.Distance to nearest Capacity.-'-' ' Disposal Field: Distance-from nearest -45 w IL__ Q"--_-Distance from foundation _ , ) Number of lines--,---------- lot line,......... =- "-- Length of each line________9� __ .. Width of trench___-- ' Type of filter r;a'ernal� Depth of filter.`materia V II 6 al----- f Total length--- ........ . Seepage 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-----I = Depth...........' - --Liquid Capacity-. p tY -------------------------gals. rl, Privy: Distance from nearest well---___--_/_.-------------------------------------Distance from,nearest buildm ❑ Distance to nearest lot line-_- _.--__--_-______._ :_T - • i ••-----------•- -- and or repairing describe :__ __.. - � r <•� ••------- Remodelin ------"----- o g / p g ( i j .. r1-- `✓y✓t__ 'r ...___,15r__ t - ------ ------------- ----------------- t. ---------- i --•--------------------------•------ -----•--•------ --••---•-------•--•--------•--------------------- 1 I hereby certify that I have prepared this application and that the work will be done'in accordance with San Joaquin County ordinances, StatVlas, bad ules and�reg{ulffpp..i�+Lri-*ons of the San Joaquin Local Health District. A = r 7 1 (Signed) . ... •----- ---: Owner and/or Contractor) sy________________ _ _____ __.._--______-_____.__.__•_-______-__________ f ..---•-------=•------••------------------'------ _(rifle) -- - •- (Plot plan, showing size.of lot, locatia i of system in relation to wails, buildings, etc:;can be Fl ce'd an reverse side). `FOR 6EPARTFAENT USE NLY— �. s APPLICATION ACCEPTED BY_---------I .______ -_ .- � C---- --- . f -- - -- --------------- -- ----- -•- -- �- --•---• DATE_..--- - - ---~-�-�--r------•- �., BUILDING PERMIT ISSUED: --~ '+A -`-_ T - = -----i EVIEWED BY--.---- -- , _ ,.._.. -- _ t G ------------------------------------ - -------- •-----•------------ ----_- Alterations and/orrr recommendations:_.._ �-- /-1- .� � .4 T QATE___.--.:.---••_--- - _ _ � ::� . .. .. ......r. z � Z IF NAL INSPECTION BY: .........._--------' r' Date...... --------------------- SAN jbAQU IYLOCAL-HEALT DISTRICT 130 South American Street 300 West Oak Street ° 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California $5 9 REVISED 8-S9 2M 5.62 ATLAS "'