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FPR OFFICE USE: Permit No. (complete d--------- F4 .h = .__ APPLICATION R Si�NITATION PERMIT ------ ------ l _ - Date Issued kP1_._ [Complete in Duplicate) -____-___.__-__-------------- This Permit'Ex ires 1 Year FroinDate Issued , Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work',herein described. This application is made in com pl iance^with County Ordinance No. 549. II' JOB ADDRESS AND LOCATIO ----.1/-j1lI0--U1---- - - --------------•-------------------------- �----- -•-• ' "----------------------------- -------------- -----------• t Owner's Name-------� ----•---;. � � �---'---------------------------------------------------- '•-------------_------------- i. -----------• - Phone-----� '--..0 ------------------------------ , Address---------��.'�-f✓---- --------------------- �•-------------------------------------....-----------------••------------------ l ...----------•-------------. ` _______________ '1 Contractor's Name------- --- --------------------- -- --.._. Phone =' Installation will serve: Residence 1g,"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ _-_ Number of bedrooms _ __ Number of baths ___/__ Lot size '---------------- t Water Supply: Public system El Community system El Private [L�Depth to Water Table ._7��t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0--15ardpan Previous Application Made: (If yes date....:...............)_-No [P--"-New Construction: Yes �No ❑ FHA/VA: YesNo n .0 TYPE OF'INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted'if public sewer is evadable within 2 -------- 0 feet.) Material__4�._�__._ d-+�'_"'-�- - Septic' Tank: Distance from nearest w�e}ll_____>�_�_- _Distance from foundation_- �l. No. of compartments----eC'-----------------SizeJ_X!t,)6 i4-'_.---Liquid depth--;T--- ---------Cap city f� ------- Disposal Field: Distance from rolin nearest well_.tes�-0._____Distance from foundat'on-__f�_--____=.Distance to nearest lot line_`_______ 6 i Number o ± _-- -_Length oLo f each lin Q_'__f' s:4>r.Width of trench..Ay__ _-______-'------ ----- Type of filter material Ln �1Ef'�--Depth of,filter material_---I� _----Total length____ ---- - '-------- v Seepage' eep g I est well t _.__Distance from fo..urndation______ : _.-_.Distance to nearest rest lot line 'Pit: sanceonear �n,4_ _-Size: Diameter-------- --------De th_!Number of pits.---------r-------_ Lining material Cesspool: Distance from nearest well-._______.__-__Distance from foundation--------------------Lining material--_!-------------------------------- O ' ❑ Sze: Dameter---------------- _---'------ -:-..Depth----- - ---- ------------'----------------------Liquid Capacity-'-�___-__ _ -'-----------gals. fl , t Privy: Distance from nearest well----------------------------------------- ______Distance from nearest building-.------- ___- _-_________---____._---- I ❑ _ Distance to nearest lot line '- !I------------------------------ - SY Remodel ng'and/or repairing (describe)------------------ -----11�r�ri _ 4 11! u ------------------------------------------------------------------------------ ------------------------------------ -----=---------°---------------------------------------------------------------------,---------•------------------------------------------------------------------------------ --------------- - I hereby certify that.l 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. i; 4;Y' _ z -------------------------------- ' -------------------------- --- .- - or Contractor) (Signed)----------- -•--- --- -------�sfem v (Plot Ian, showing size of lot, location on relationto wells, buildings, etc., can be placed se side]. B ' ---... _ l [ P g FOR DEPARTMENT USE ONLY IE APPL€CATION ACCEPTED BY ` --= ----------------- DATE - f REVIEWEDBY-----------------------------------'------------------------------ ------------------------------------ DATE----------------- =� Alterations and or recommendations:._.____.. 2 - ---- �- -- - BUILDING PERMIT ISSUED.--------------- ----------------------------------------------- ---------- ---- DATE--- ----------------- ---------- _--- I' I --- 7�-�L�.----"---- Date--- -------- -� -- F€NAL INSPECTION BY:.---- _��_�------------- - -----• '- ----- -'---'- - - ' -'� ----'-'----'-- - - ----'---- f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 304 West Oak Street 124 Sycamore Stree205 West 9th Street- Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-S9 3M 3-'63 F.P.CD.