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FOR OFFICE USE V p //63 \ a / APPLICATION FOK- ANITATION PERMIT Permit No. (Complete-in Duplicate) Date Issued/�... ----- .r�____-__----�- ----------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descrbed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-. �' •L VQ -----/� P.�.f G.- c -- ----------------------------------•----------------------- Owner's Name---lTfi�.• ------------v7 ^�-----•-- .:-Ch_-,5- --- 000. - Phone _ ^^ Address-------1,65-0_&------------; � � � ---------- -------------_-- A^--.-----------f-----------------..._ Contractor's Name--------,5-�/�--�...----------- ----------------------------------- ------- ----------------------------- ---------------- Phone_---.lam---....--------------- Installation will serve: Residence, Apartment House ❑ Commercial E] Trailer Court E] Motel E] Other ❑ Number of living units: �_.__ Number of bedrooms_.__ Number of baths...Z-- Lot size ..... _.. ..... Water Supply: Public system ❑ Community system ❑ Private X Depth to Water Table_a- ft Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam K Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date....-_--__._.._. I NoX New Construction: YesX No ❑ FHA/VA: Yes ❑ No) 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-A0.0 .---Distance from foundation_/O�---------Material ...C'__Q"Vc.J--p7 i - ----- ----Ssze--- U Q,�f'-_Liquid d�th-----Co ----- ------- x P Y No. of compartments-----.! - Disposal Field: Distance from nearest w ell __Distance from foundation./Q___ .__...Distance to nearest lot line._.S-._-_..._. Number of lines-------Z-........ .........�en of each line-- ---_7_ _.f____..Width of trench.-..__ ______.._.___._.___._.. Type of filter materials-:C/ �!__C..___ e tN of `filte'r material -4J.��--.-_.-TotaE length____..1-`�___________ -------- Seepage Pit: Distance to nearest well-___+'6kW---Distance from foundation__ 0_/-_-..Distance to nearest lot line_ S$_l_.. Number of pits-_2 Lining materiaE /4. Size: Diameter__�3_.3.//.... .Depth-. r Cesspool: Distance from nearest well ----------------Distance from foundation.-............... ..Lining material-_.__________________________ ❑ Size: Diameter. . ------ ---- ---------- ----Depth--- - -...--------------.--------------------------.Liquid Capacity-------------- -------- ---gals. Privy: Distance from nearest well .....................___._---._.__---__-_._...Distance from nearest building----- j----------------------------- -._. ❑ Distance to nearest lot line ----- ------------- ----- - ------ ------------------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe)---- ----- --------------------------------------------------------------------------•------------------------------------------------------------------- i rr'r 3 --------------------------------------------------------------------------------.--------------=-------------------------- T -a -- - -------------------------------------------------------------- --------�-------------- -it%-------- I I hereby certify that I have prepared this application and that the.work will be done in accordance with San Joaquin County ordinances, St , and rules and regulations of the San Joaquin Local Health District.a 00 . r (Signed)----C ----- ------ ----------- ---................................... ---------------------- [ / ) ...... . ...... .... -. Owner and/or Contractor BY: ---------------r---------- -------= - ------- -----[Title}--------- ------ ............. ........ ----- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be(rplaced on reverse side). Y— - # i i FOR DEPARTMENT USE ONLY r �.. r -� r DATE = �P. ------------------ REVIEWED BY-------------------------------- i DATE APPLICATION ACCEPTED BY-_ - ----------- - ------ ------- ------ ------ ---------------------------------------------------- fl__0- 7<----I BUILDING PERMIT ISSUED =.---- '--- - ----- DATE----- - ------------------- -------- - ---------------------- -- --------- - -- Alterations and/or recommendations:__- ..._.. ... .. --..__-----------------__._ --------------------------••-------- -------------------------- ----------------------------------------------- ----------------------------------------- ------------- FINAL INSPECTION BY:... _. . ._. _._t _, '�-� Date.----- --- - - ---- - - -------- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street 5locklonr California Lodi. California Manteca,California Tracy,California E.H.9 2M 1.67 Vanguard Press i