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APPLICATION FOANITATION PERMIT Permit No. 1Z (Complete in Duplicate) Date Issued -- - Application is hereby made to the San Joaquin Local Health,District for a permit to construct and install+he work herein described. This application is.made incompliance with County Ordinance No. 549. JOB ADDRESS ND LO ON -- �e{ � --- 1r i 'V o --I__�{/v l!^--!4 �f�rf�--------_ ------------------- Phone--a--- O`wner's Name_________ 1--_ -- - --- -�--�• ---------- Address---—_6_q_o. ----- --�--�---- 6-.-M----ri- -.�- ------------------------------- - - ----------- j�� - i •----------------------- Phone_+�Q____ n y y ----- Contractor s Name__. -'��_ :_��1-.-`•`ti=`�-�r-------------- ----------•- ------------- ------- Installation will serve: Residence 6a Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ �1 ❑ Number of living units: J____ Number of bedrooms ___t___ Number of baths ___t____ Lot size ________________ 1 Water Supply: Public system ❑ Community system ❑ Private [B-16-epth to Water Table -------- it. Character of soil to a depth of 3 feet: Sand.O Gravel ❑ Sandy Loam ©Clay Loam ❑ Clay ❑ ..Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ©/New Construction: Yes ®�'No ❑ FHA/VA: Yes ❑ No [] TYPE OF INSTALLATION AND SPECIFICATIONS: ,. , (No septic tank or'cesspool permitted if public sewer is available within 200 feet')F. r p Septic Tank: Distance from nearest well__ __ -___Distan e fr m f unda !on-- ___.______.Material__ _._-_____ _''` ' `----_.--- y rr �}` Na. of compartments-____-3'--------------`-Size___r� '#__ --4---?�- Liquid depth---- --`t`- --------Capacity - - - Y j-- Disposal Field: Distance from nearest well__ U____-__Distance from foundation___ ----Distance to nearest to i line__�`J______- �' Number of lines-------1------------- -----------Length of each line-------�� ------Width of trench-----2- ----- Type of filter material___ _____`_-Depth of filter material___..�_G_�_____.___Total length_______ _ __________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- Number of pits----------------------Lining material-----------------------Size: Diameter------------- ---------Depth-------------------•------------ Cesssppool: Distance from nearest well-------------_____Distance from foundation-------------------.Lining material__._____.-_-___,_____._______________. Size: Diameter------------------------- ------------Depth----------------------------------------------------Liquid Capacity-------------------- gals. ElI ----------------- Privy: Distance from nearest well------------------ --------------- --- -------_Distance from nearest building---------------- ----- ❑ Distance to nearest lot line-------------- --------------------------------------------- ------- -- l --------------------------------------------------------------- (� ' /� 1 e g 4' �C +`Jv--- � �rr 7 ----• --------------- Remodeling and/or repairing (describe):_-__________ .-�_--__ ...._ -- - ------ ------------------------------------------------------------------------- f ------------------------------------- 1 -----------------------•------- ' 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. � � --_--____ ----------(Owner and/or Contractor) 5i ned -- -------------------------------- ----------------------------------------------------- �C 1 1 r ------ -- --Title_.' -�ip_'_�__�!' ----_----F ----- -------- B1�� -- -------V:- A __ `- ------ -------- ( ) J [Plot plan, showing size of , location of system in relation to wells, buildings, etc., can be placed on reverse side). f�. FOR DEPARTMENT USE ONLY x ' APPLICATION ACCEPTED BY-------------------------------------------------------- -------- ------------------------- DATE------------------ -----------------� ------ REVIEWED BY------ ------------------------------------- - 1- -- ----------- DATE f ' ---- --------------- BUILDING PERMIT ISSUED------- DATE------ - ------------------------------------------------ ------- --------------------- ---- Alterations and/or recommendations------------------------------------------------ --- -------------------------•------------•---------- ------- --------•-------•----------------------------•---------------------------- --- -------------------------------I----------------- --------------. FINAL INSPECTION' BY:._ 14 Date.... . [ 5AN A UIN LOCAL EALTH DISTRICT i 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revisea 1.57 F.P.CO.