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1, Is�'y ✓ APPLICATION FOCANITATION PERMIT Permit No (Complete in Duplicate] / This Permit Expires ] Year From Date Issued Date Issued --- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ord' nce No 5 /LCATIONL,e?aJOB ADDRESSAND - -- __-.. -- --- ---- —-`-- a L / Owner's Name.._--- - `}F"- - - --------•------------ _ .l `---------- ----------------- Phone --- l . :. � ---s ---------------- Contractor's Name__ ----- ----•------------ -- Phone.... .�...._ �-_7----- Installation will serve: Residence Ap ment House ❑ Commercial r / ❑ Trailer }Court ❑ +Motel ❑ Other ❑ Number of living units: ___�_ Number of bedrooms -Z- - Number of baths __/__ Lot size-,4- JCr Water Supply: Public system Communitysystem . .--`- Y ❑ Private ❑ Depth to Water Table,*�t. Character of soiltoa depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑' No X New Construction: Yes,k No ❑ FI-EA/VA: Yes ❑ NQ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T k: Distance from nearest well m' well_..-_.-------_ Distance-from foundation No. of compartments- --- ---- ----- S .._._._.-_.._.__ . Material------------------ ------------------------------- ------- ze--------------------------------Liquid dep. ---_------------ ---- f Disposal F' Id: Distance from nearest well___________ __Distance from foundation..-..___.`..--...._.Distance to nearest lot yline_...___.__..-___- ' Number of lines---•-------------------------------Length of each line------------------------------'------- Width of french------------- , Type of filter material-------------------------Depth of filter material------------------------ See Pit: Distance to nearest wel Total length------------------------------------------ Seepa, ~_.-_.Distance.:f.rbm .. dation��___----_-_Distance to nearest lot line__SIr_` - Number of pits----- ------------Lining materia�- - -.- -- ize: Diameter-- "------ � T �'' Cesspool: Distance from-nearest well..-_.--__..._...Dist��n�c fw a+- foundation..........__________Lining material... ___.__.___ ---------------•----- Size: Diameter Depth -------------- ------ - - Liquid Capacity-.----------------------- -gals. Privy: Distance from nearest well------------------------- - ---...- Distance.from nearest build in Distance to nearest lot line.__----------------- Remodeling _ _ g and/or re air;n descrill , r r --- - -- -- . --------------- -------------------------------------------------- ---- ---- ---------------------------------------------------- ---- -- ---- - ----- - - ------ •----- ----- ----- - ----- - - ---- - - -- ------------- I hereby certify that I have prepared -his application and that the work will be done in accordance with San-Joaquin County ordinances, State laws and rule an lregulati s ofle Sa oaquin Loc Health District. (Signed)_ t2_2 r ------------ ---------------- -------------(Q BY:------------- - wn Contractor) T7 ? (Title) e r •pr -------•--------------------------- (Plot plan, show' e o ' , location stem in relation to wells, buildings, etc., can be ew rse s' i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. -. -- ----------------------------- DATE ---- REVIEWED BY --- ---•-------------- ----------------------------- i -.. ._ _. -------_------------------------------- DATE------ PERMIT ISSUED ---- ------ ----------------------- ----------• ---------------- DATE - - ;; Alterations and/or recommendations: ` �-:-!n- _-- — �y -------------------- �5, ---•--------------- ---�-- ------� - - .... '-}- _------------------------------------------------------- ---------------- FINAL INSPECTION \ -.- �``� ---------- Date_.. '- _4- -- --------------- ---------------- 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 Revised 8-'54 F.P.Co.