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FOR OFFICE USE: ------------------E--- --I -- --------------------------- APPLICATION.CATION FOR L ''*NITATION PERMIT Permit No. ........... ------------------------------- ------------ ---------------- ------ --- --- ------------------------- (Complete in Duplicate) Date Issued ------ ------------ This Permit Expires 1 Year From Date Issued Application is hereby made to thii r Sa6.Joaquin Local Health District for a permit to construct and install the-work herein described. This application is made in complpa�ce with County Ordinance No. 549ftiTY-A .' V0/9 JOB ADDRESS-AND LOC' TI K�-----A T_ --------------- ---------------- j�__y------- N_ I --------------- ----- ------------------------------ Owner's Name------------------ -- --I ---------- ---S------------------------------------------ Phone - Address-------------SY-Y----------- '_,i5 M�---------------M_T----------------------------------------------I----------------------------------- Contractor's Name----------FLLI-A-.F___k---------------------------------------------------------------------------------------------------------- Phone--------_____ :_------ ------- Installation will serve: Residence [!tApartment House 0 Commercial [-] Trailer Court -0 Motel [] Other ❑ Number of living units. --j--- Nu'mb'er of bedrooms ]--- Number of baths __Z__Lot size ------- ------------------------ Wafer Supply: Public system E] Community syst El Private 2---Depth to Wafer Table -17.- ft. Character of soil to a depth of 3 feet: Sand Gravel E] San y Loam [j Clay Loam 11 -,lay El Adobe Ej Hardpa E) Previous Application Made: (if yes,date..." ------) No 1;:!�New Construction: Yes jjT' No E] FHA/VA: Yes No 1771 TYPE OF INSTALLATION AND SPECIFICATIONS: ---(N6-se7Ptkitafik or Cesspool-perimnifted-if-pLiblit-sewer-is-available-within-200-feet.)----;-�� Septic Distance from nearest well____,5 ---Distance from foundation__-_ Materia j_<_401VC,4RAU__._M-------- No. of compartments_-_-__" 4/�y --Y,57Liquid clep�fh____ . .....Capacity-J-Z -0--- .__size__Z__ 1119 .2—. -Dispos�alielcl: Distance from nearest--well...5-0----Distance from foundation---1�----------Distance to nearest lot line---- ----------Length of each lineYA-Y-0-11-30-10liVidth of trench 2�t#t_--------I-------- Number of lines______ >............ -------- ----- Type of filter material---90-j04�_Depth of filter material-----T _2 ----Total length----------------/ -----________.___- Seepage Pit: Distance to nearest well-----------------------Distance from foundation------------- ------Distance to nearest lot line--.-------------- 1771 Number Of pits---------------------Lining material-----------------------Size: Diameter---_____---_.-._...__.Dept h--- ----------------------------- Cesspool: Distance from nearest well-__-___-________Distance from foundation--------------------Lining material__-------_._--"____-_"____-_________. ID Size: DiameferiI------.--=-------------- ---------;Depth---------------•-------------- ----------------=__Uquld Capacity---------- ------ ..........gals. Privy: Distance from nearest we€l----------------------------- -------------------Distance from nearest building__________-_---_------_-__---.-_-.__.-._. ❑ Distance uilding--------------------------------- Distanceto nearest lot line-------- ------------ ------------------------------------------------------------------------------------------------------------------------- ITO I (describe):_/itor _U 5 F_ /-Tf-+ ke"reds ri-rigo-1midtf� -------Drsier_N_P�X? -----W_ - ----------- -- --------------------- ---I---------------------------------------------------------------------------------------------------------------------------------------------------------------- -----T19-U-4--- 15,&N_D x _y----- ---- --- --- I AF- / __7 _BF------A------104_Vkjg�-----OF ___6A_N_D------ ......4,E Fj-a-# ------- _U F I hereby certify that [have pre'pared this application and that the work WIT done itgdlcofte wOfffJoaquin County ordinances, State laws, and rules a regulations of the San Joaquin Local Health District. t-r (Signed)----je&e4-------- --- - -- -------------------------------------------------------------------------------------towner and/or Contractor] By------- -----------------------------------------------------------------------------------------------------(Title)- --------------------=.... .... ----- - - -- --- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- -----------------------I------------------------------------------ DATE--------�-------- REVIEWED BY -- DATE - - ------------------ - BUILDINGPERMIT ISSUED-------------- ---------------------------- ----------------------_-------------------------------- DATE--- ------- --------------------------------- --------------- Alterationsand/or recommendations:-------------- - - ---- -- ---___---------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- i -------------- ------------------------------------ ------------------------- ---------------------------- ---------- -----------------------------------:--------- ---- ------ -------------------------------------- ---------- ------------------------------------------------------------I------------------ ------------ ------------------------------ ---------- ------ ------ --------------- ---------------- ................. -------------------------------- - -- ------- ....... ---------------------------------- ------ - ------- ---------------------------------------------- FINAL INS ----- Date-_- - 7------ 1�4------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxeltan Ave. 1 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California :TracYr California Vv