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FOR OFFICE..US& - ------- ---------'- { ------------ --------- r_ ____________ _ F# ______________ ________________ APPLICATION FORS ANITATION PERMIT Permit No. ti --- ------ ------------------------------------ - - (Complete in Duplicate) ' {= ------ ----------------- ----------'----.--...- This Permit Expires 1 Year From Date.Issued Date Issued ./-r_ --- .--- p icaflon'is ---pplicafion'is hereby 'made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This,appl,ication is made in compliant with County Ordinance No. 549. J i OE3 ADDRE55�AND`LOCATIO _ al l�----��t,?l-S� 1 J��1------- = 7�---Avs-�- z-V-------- - yry ` 4 Owner's Name-= __-___ _ -------[�_QC7 � .E�'} ---------------------------- Phone-----------•-•--_---------------- E[g6 i f Address rr : --T Box 12- = 'f` 1 .. . -------- -----------------------------I_....-•--_.... 'Contractor's Name-------0W1_nl-%f__�1__,-------•----------- . -------- -----------------------•------------•----------- Phone..----•---------•-------••---------. I,.nstallation will serve: Residence _Apartment House ❑ Commercial E] Trailer Court ❑ Mote! ElOther ❑ ± . Number'of living units: __(---'Number of bedrooms .a__ Number of baths i;?�_ Lot size ------ € Water Supply: Public system ❑ Community system ❑ Private 2---D to Water Table fv ft. fP f Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑. Adobe ❑ Hardpan ❑�: Previous Application Made: (If yes date_____.__..,____..} No/2---New Construction: Yes Er<❑ F}-IA/VA: Yes Er-'No ❑ I' TYPEOFINSTALLATION AND SPECIFICATIONS: _ Nose tic tank or=cess ovE= ermined if ub ic`se e�is available within-200 fayet j � P P P p- w-- _ _ -- Septic Tank: Distance from nearest well--_:570..-Distance from foundation__ 67--. -- Size u No. of compartments------- ----- i 41-—X q P, P Y _ty�j Disposal Field: Distance from nearest well -.--Distance fr _- from foundation40--------.Distance to nearest lot line-_47-1 ;-- t �� 1 Number of lines----------------- ---------------Length of each line--- _`f-_�� _._.Width of french---------�_..,............. Ic Type of filter material__./T( C}'-,__Depth of filter material----1.17------------Total length----- ____;l_ ____'_._.---- �� Seepage Pit: Distance to nearest well--------------___----Distance from foundation-_-------____.__-.Distance to nearest lot line----------------- El Number of pits-'--------------------Lining matercal-------------_.___.�:$ize: Diameter.------------------ _ -.De tn.____.-_-__.-.•----------- --- � —} � I , Cesspool: Distance;from nearest well______.__,._*Distance from foundation____________________Lmin material_.._.__.._..___._____._-. ❑ Sze: Diameter___ i r' De th_.__._._ -,- - P �----Li Liquid Capacity ------_- } t � -------- --- -- •-�-------- -# - q p Y-�----- -------gals. Privy: Distance from pea rest well----------------- -------- ---------_.,Distance from nearest building________________--.________..._ ❑ Distance to nearest lot line--------------------------------------------------------------- Remodeling and/or repairing (describe):---- _57-EFjV__7--------n(eV.----- kE. t G& i7.----- 5 _ ----•- FloR------� VVJT ) = - n! p--=----.-•--------- --------------------------•-------------------------=-- 1 - T R.o 41 1 -----------------------------------------------------------------------------------------------------------------------.___--------_-___-._-____-------__-.__________-.-__-__--_---___._-___-_-.._____---.---.._____._.._--..._ T I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i ordinances, State laws, and rules and regulations of the San.Joaquin Local Health District. ) f - - --tet -�� (Signed_ , ----- --- --- r c Y• % - :.-. : ---....�, Tifle) _ n_a� - r l and/or ) ---- --------------------------------- --_ -- a (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'ACCEPTED BY---- -- _ - -------------- ------------------------------------------ DATE------ 77 — - REVIEWED BY = --------- --=- DATE l� Q - BUILDING PERMIT ISSUED ----------- --------=--------± DATE = Alterafions'and/or recommendations ____________________________ -------------------------------------I-------------- ------ ------------ ------------------------ ------------ ---•----------------------------------------------------•------------- ----- ------------- •--------------------- ---- ----------------------------------- ----I----------------------------------------------------- -------------------------------- -------•------- -------.-.--.---.- ---- -------- -------------n--- --- - .-- -= --------------- I �. FINAL INSP "' Date - SAN JOAQUIN LOCAL HEALTH DISTRICT s 1601 E.Hazellon Ave, s 36D West Oak Street-. .rye 124 Sycamore Street 205 West 91h Street Stockton,California { Lodi.California dam' Manteca,California Tracy,California F.P.CO. t '