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F FOR OFFICE USE: I ------------------------- ANI _ APPLICATION"`FOR7S7ATION PERMIT Permit No. __.-_r... -------------- --- -----.--.---------- (Complete-in Duplicate) 3 --- ____________________ -------------------__________.__. r This Permit Expires ] Year From Date Issued Date 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 compliance with County Ordinance No. 549. z JOB ADDRESS AND LOCATION------------5.---- --- ------- ------ --------=- `a --------------- -------- ! -) lwl Owner's Name tiF:# = 1 ------ _r�� 1-._ Phone------------------------------------ Address �..._-•-•--....._>O- ---------x.*TQTRCr ----------- •---------- ------------ ---------- i , s1 e actor s Name_.. iPi��-- --�---`- • •---•----•-- -----------I--------------- ------- ------ ----------------------------- ---------........ Pilone.-----._...-----------•--...---•--- Cont Q." __ -. Installation will serve: Residence House ❑ Commercial +❑ Trailer GourtyQ Motel ❑ Other ❑ •Number of living units: _ ____ Number of-baths-� ize__'_�'•___'.____ iri --_-- Number of bedrooms �✓ .-- - -- .- ------------- I Water Supply: Public system ❑ Community system ❑,,,,,Peiva-teWDepth to Water Table/ _ ft Character of soil to a depth of 3 feet- Sand ®/Gravel,❑ Sandy Loam ❑ Clay Loam-❑�C-lay El Adobe ❑ Hardpan ❑ Previous Application Made: {If yes,date___________________ ) No,Z3/"New Construction: Yes ®'Na E] FHA/VA: Yer"u No ❑ I TYPE; OF INSTAL1rATION1AND .SPECIFICATIONS: No'se tic otan or cess ool ermlt#edstf public=Hewer is7a—Vailable;within 200 feet. . •,a - = i( P P P },x : r p 1 y ,.eare. _e �.ti-- - f anon- -=---. Maters I_1C4?/VCRF I --- 4 ` 4 Se tic Tank: � �' �No} of compartments t wei�W_"_-- - SD'�zea��f��F_•Li.quid depth_.-.5.��-.____CapacitY ©_�_ ---- Disposal Fieldr Distance from nearest wee I)---5a 15+stancefrom" oundati -10-_-.__"-..Distance 4o;nearest,,lot line____ Number of linelis.----------------------------------Length of each e__..___ -__---�--------------- of.trench------------------ - -----••- i p ype of filter-materiaL_�t"J'-C6.....Depth of filter mater al4_.-,1.q.__..-_-_Total length-------------/14 --------------- q f Seepage Pit:y Distance to nearest well__----_................Distance from foundation_____-_„___„-,_.._�Distance to nearest lot line----------------- C ❑ _. s Number of pits _ : _ .....Lining material Size: Diameter..- =----__ -,--•--Depth--------------------------------- Cesspool: I Distance from nearest well ........Distance from foundation_-_-I Lining material--------{ _________________ _________. }f Sie: Diameter -- ------------- - t D _ -__- e th._.-____---_-----. "_Liquid Capacity-.Dt � - ---------------------- - ---- q --------------------gals. Privy: Distance from nearest well____----- �____ _ .......Distance_from nearest building_________________________________________ Distance fo nearest lot line ---------.._____------------------------------------------------------- Remodeling Viand/or repairing (describer------------------- -----'-- - - --------------- -------------------------------•---------•-------- --------------------------=-------------------- # �-- f r, ---------------- ------------------=---•---------------- ---- -------- - ------------- ------------------ 1 i i I hereby`cerfify'that I have Qr'epared this application ;and that the work will be done in accordance with San Joaquin County ordinance a laws; and rules and r gulations of San,Joaquin Local Health District. d1 r(Signet _ b --- r i (Owner and/or'Contractorl i 3 (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 IO APPLICATN'ACCE-PfED BY------ 77_13-00------------------ ---------------------------- -------------- DATE-- REVIEWED ATE-REVIEWED BY............. -----------_--------------- ----- ----------------------- _.------ -.............------------------- DATE----- - --••--------------------- BUILDING PERMIT ISSUED-------- -- - ---------------------------- ------------`---------- -------------------------------- DATE_----- ------------------------------------ -- -----------•------- ----------------- Alterations and/or recormmendations:............ --- ------- ------------------------------------------------------------------------------------------------ ---------------- ---- ---------:-- -�;-------------- --------------------------- -------------------------- _. _______________________________________________--•---_ •- ___ _________ _____--_-_-___- ._._- -___ ._._._______-._. --------------------- __-___----_---_____---_._._------_-.-._..----------------------- ._-__--_____. ------------------------------------- --- _ _ _ ____ __._.-. .-_-.-"_"_____- ...___.. --- _-_- - `4 FINAL INSPECTIO Date_...-.- ..-_1_ ` SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E,Hazelton Ave. 300 West Oak Street 124 Sycamore Street 245 West 9th Skeet Stockton,California Lodi, California - Manteca,California Tracy,California E.H.9 2M 1-67 Vanguard Press t