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APPLICATION FOR _. .NITATION PERMIT Permit No. .... .r.l (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date 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. 549. JOB ADDRESS AND LOCATION______________________$1�___LAF011ette_----- N. of HELrding.. -- W. of Palm Av. - Owner's Name---- ---Kr-o----and... rs. BudMcKeePhone Ho„ 2-2018 Address--------------------$1-'-5----La.021._411A--------------------- Contractor's Name----------------------D-e - a Se tic Tank Service, Inc. 3--1269 ------ ------------------------------------------------------------------------------------•------ Phone.-- HQ•-••---------- Installation will serve: Residence ® Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel [❑ Other ❑ Number of living units: ___1__ Number of bedrooms )__._ Number of baths _;-_____ Lot size ---5o--- --- 0_________________________________ Water Supply: Public system K] Community system ❑ Private ❑ Depth to Water Table4-0--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe® Hardpan ❑ Previous Application Made: Yes ❑ No [jj New Construction: Yes [I No ❑ FHA/VA: Yes [_1 Nok] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material __-____.--___________-_-_----___--_________- ExiiMing No. of compartments--------------------------Size--------------------------------Liquid depth--------------------- ----Capacity-------------------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line_______._________ ExiUing Number of lines-----------------------------------Length of each line-----------------------------_Width offrench_..__.-_-_____-___-._---___-_--.____ Type of filter material.------------------------Depth of filter material----------------------- length____-.-_-----_-_-----_ Seepage Pit: Distance to nearest well______A ____ Distance from foundation-----1B __.___ Distance to nearest lot line____5t------_. \ Number ofits_--_-__Z_______ Lining material._-._-rOCk_____S¢e: Diameter-----3-3 1t Depth--.9-5-1 max_e______ Cesspool: Distance from nearest wail--------_--------Distance from foundation.__._-___-__..___.Lining material__-____._..__...__.____.__________ ❑ Size: Diameter--------------------------------------Depth------------------------------------------------ ---Liquid Capacity----------------------------gals. Priv Distance from nearest well-________________________________________________Distance from nearest building Privy: � ❑ Distance to nearest lot line---------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):____--adding Filter__Bed--- o---- xisting System --------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- -------------------- ----------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------•------------------------•-------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) Delta-_a_e e &I3k_.B_ 'V CBS_._ nC f------------------------------- ----------------•------------(Owner and/or Contractor) By:------P_eS'x'_y-.--Q-.--W_aZt1._a11-------------------------------------------------------------------------------(Title)------- -- (Plot (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 --- APPLICATION ACCEPTED BY__ _________________________________________ DATE__✓._' rl - ------------ ------------------------------- REVIEWED BY- - --------------------------------------------------------------------------------------------- ------- DATE------ ------------------------ ------------------- ---------------------------- BUILDINGPERMIT ISSUED.----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:-------------- ---------------------------- --------------------------------------__------_------------------------------------------------------------- ----------------•--••----------------- ------------------------------------------------------------------------------------------•--------------------------------------------------•----- ---------------------------- i --------------------------- _______ _______________ ______'__._ __ _ ______-______________________________..____-_______.____________.___________ __ __._. ___ _-----. - ------ ----- �3 �,�---.--- - -------- -- ---------------------------------------------------------------------- ----------•------------------- 6 _Z3-4�/ FINAL INSPECTION $Yi.- .: Date.- ;/----------------------- --------------- SAN ------ -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-92M Revised 8-'59 F.P.Co.