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�( ��/ APPLICATION FOR .,�.NITATION PERMIT Permit No. _-_�7--�_�.. -a ted- •u�,( (Complete in Duplicated I �( �' Date Issued � U Application is hereby made to the Sat n Joaquin Local Health District for a permit to construct and install the work herein described. I �..�This application is made in compliance with County Ordinance No. 549. I ,:..JOB ADDRESS ANDATION..--- ------ ---------- ------------------------------ _&, !�� Owner's Name------- ----- -- b 2,S 6 ° . ------------------------------- ---------------=----------------------------- Phone- ----------•--`----- -•--------- Address :............ -ems = , Contractor's Name_-- D ---------------------------------------------------------------------------------------------------------------- Phone-„ ( Installation will serve: Residence Q/'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r Number of living units: ---L__ Number of bedrooms -- -- Number of baths ---L_ Lot size _J15_'t'7 K___/- -------_-._-_-------_ Water Supply: Public system []Community system ❑ Private ❑ Depth to Water Table -_ ft. Character of soil to a depth of 3 feet:_ Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 52[/Hardpan ❑ Previous Application Made: Yes ❑ 1No Rr� New Construction: Yes R-"No ❑ FHA/VA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: {No septic tank or'cesspool permitted if public sewer is available within 200 feet.} Septic,fT�nk.-, Distance from nearest well-----------------Distance from foundation--------------------Material -----.-----_-------------------_------.---.----. No.'of compartments--------------------------Size---------------------------------Liquid depth--------- -------- ------Capacity--•-------------------- Disposal Field: Distance from.nearest well.-_-------------Distance from foundation------------------..Distance to nearest lot line--------.----.--. Number of lines-- _------------=------------------Length of each.lire-----------.------------------Width oftrench--------------------------------_-_ Type of filter material------ ----------------Depth of filter material----.___-__---------..-Total length------------------------------._--_-_-_--. .4 . A Seepage Pit: Distance to nearest well,.-- II.0.91--------Distance from foundation_ M -�.�__-�D st ice to nearest lot e.-��_--_-- .- [y� Number of pits-1--_------- Lining material_- ---------Size: Diameter--..*�._.-------Dept€ _-: s5--------------------- Cesspool: -- -------- ------Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_--------------------.-_-------.___-----. ElSize: Diameter------------------------- -----------De th------------------------------------------------- Liquid Ca aci# --gals. \l Distance from-nearest well - # l -_Distance from nearest buildin Y 9 ----------- ❑ Distance'to nearest lot line------------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)------- ------ I•.4-cy _ ------------------ -- --- -------------------- --------- -------•--- ----- ------------------------------- --------------------------------------------------------------•---..-----------------------•----------- ------------------------ ----------------------------•----------------------------------------------------- -----------------------------------------------------------------------•---------------------------------------- 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. f -. [Signed} ----------- - ` ----------- ------------------------------------------------------------ (Owner and/or Contractor) Y B : -------- -------------�'./+ =�-u----------------------------------------------------------------------Title]------ ------- --'-?------------------------------ -----------(Plot plan, showing sixe o ot, location of system in relation to wells, buildings, etc., can be placed on reverseJside]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- UK-_ ------ ---------------------------------------- DATE-------- REVIEWED BY---------------------------------- '.-� -_ - DATE ;1 BUILDING PERMIT ISSUED V DATE--------` - - -- Alterations and/or reca mendatia s: r � �_ P� � � %------------ � t - FINAL INSPECTION BY:- - �7 -- ----- --------- ------ Date-- -----/`-- ------------� 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-9-2M Revisea 1.57 F.P.CO-