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FOR OFFICE USE: ��- .r• ----- ------------------ ------------------ ---- --_ _--- APPLICATION PORE SANtT- ATION PERMIT Permit No. ------------------------- - ------- --------- {Complete-in Duplicate} Date Issued ---Q�--.-1 This permit Expires i 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 described. This application is made in compliance with County Ordinance No`549. 1 #: JOB ADDRESS AND LOCATION MDQ -��®------ /VTC [ I = Owner's Name-------- -----------/All-,A N-� ;_1 ff / /t}_ _ l �}' ---- ---------------•--------`----------- Phone------------------------------------ Address-------------------- , ,�- }} tom = _ :_: • ---------------------------------------•-- Contractor's Name------OWWJ�[------------------- ----------- Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial railer Court ❑ Motel ❑ Other ❑ Number of living units: —-Number of bedrooms -------- of baths. �- Lot size ____� 4C__ � _-^-------------- Water Supply: Public system �ommunity system ❑ Private ❑ Depth to Water Table ft MT"CA Character of soil to a depth of 3 feet- Sand A5'*"Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date------------------- ) No New Construction: Yes No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: No.se ticrtank or_cess ool ermitted-if ublic sewer.is available within 200 feet.) Septic Turk: Distance from nearest well `-- ._ Distance f�m foundaticn_fO-____ - Material ___ 1 Ck xfxs f � N of compartmy e�s_____. __ Size__ ________ __ __- _---- --_--Liquid depth-._�{/ �,r_... _90 0 Id Distance from nearest well- y'�-.-Distance from foundation__I_0--------Distance to nearest lot Number of lines._______ ___- —""' ter"`— of" e �' _______________Length of eacl`line ___��._. __-._._-Width of trench-.__�.�____:_ � iew _ __ �_____________ Type of filter material.__ ._ Depth of:filter: material-___.-I-_______-_Total length--- _ Seepage Pit: Distance to nearest well ____________________Distance from 4foundation____.,___,,._-_.,__,Distance.to nearest lot line----------------- ❑ Number of pits--- ------------------Lining material-------------!-------- Size: Diameter-----------.__----..-_Depth---------------------------- 1. 11 - Cesspool: Distance from nearest well ________________Distance from'foundation..... _......... ..Lining material--------------------------------------- 7-1 - ...-... = Liquid Capacityy -gals. 4; Priv Distance from nearest well_________________D_ -_}h:__._.- - Distance from nearest bu16in Privy: ❑ Distance to nearest lot line-------------------'`-'--. -----.., t - I - ------ ---------- � • Iwo Remodeling and/or repairing (describe)_---------_----_--------------- -----------•---------------------- ;; r I ------------ -- I hereby certify that 1 have prepared this application ani that-,the work will .be.done in.accordance with San Joaquin County ordinan s, St laws, knddrules and regulations of the San*Joaaquin Local Health District-(Signed)- --------- -- --------------------- -- -- --------- ------- ---;----------------- -------- (Owner and/or Contractor)y s - _ ---------- {Title)_ ' - - ,_t. :. (Plot plan, showing size of lot, location of system in relation t' wells, buildings, etc., can be placed on reverse side. t ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ' -------------------- ------------------------------ DATE------- ._:4. ------------------- REVIEWEDBY---- ------------------ -------------•---------------- --------------------------------------- -------r-------------- - ---- DATE--.- BUILDING PERMIT ISSUED-------- ----- ---------------------------------------- ----------- _-- --- ---- - - DATE t . � ;W -------•--------------- Alterations and/or recommenda+ions:-_---_--___ ------------ I ; -------------------------------------------------------------- T- 0 FINAL INSPE N BY 1 Date__. a SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 245 West 9th Street Stockton,California Lodi. California ` Manteca,California Tracy,California E.H.9 2M 1-67 Vanguard Press