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rte_ �- - APPLICATION FOR SAdTATION PERMIT Permit No. (Complete in Duplicate) .t._ _ -- Date Issued --- - -r�3- This Permit Expires # Year From Date Issued i 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 wifh County Ordinance No. 549. JOB ADDRESS AND ATION_____ Q_ ----- -------------•---„aJL__,? -------'4�^__ -- ------------------------------------------------- JOB . - ----•------•---------------- K� ------ ' Phone__.-------`-:--:---•---••---------- .-----/ ------------- ...- ��- ,Owners Name--------- r ------------- 0/1 Address--------------------------- -•^•----.... Phone---------------------- . _ -----•---------- ----- . Contractor's. Name- Installation will serve: �Residence ® Apartment House [ICommercial ❑ Trailer Cour} ❑ Motel ❑ Other [I Number of living units: _____ __ Number of bedroomsr�j__ N umber of baths_ Lot size .____._ Water Supply: Public.system ❑ Community system �rivate ❑ Depth to Water able - ft. ar Character of soil to a depth of 3 fest: Sand ❑ Gravel ❑ Sandy Loam ElClay Loa jmI ❑ Clay ❑ Adobe idpan C] Previous Application Made: (If yes,date____________________l No �ew Construction: Yes! 10 ❑ FHA/VA: Yes L4t.�o E] \J� TYPE OF INSTALLATION AND SPECIFICATIONS: !'” (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well___.< _. Distance from foundation__ _ Matenal _._ ._._ .... Nc. of compartments--,:?- ------------- Size__„ Liquidrdepth------_ _-" Capacify_.._)-_-_-___;__- ---- i # e Disposa field: Distance from nearest II, __Dis#once from foundation___ ._ _ Distance to nearest lot11li��ne_______ _____ `* " GF —Width of #rencli': ?'1------------ Number of lines_-_-_ _-- __-Lengtlof eache__ kj----- --- Type of filter material-Vii-,v! f filter�maten l_ ' -Notal length__ •--r'----------•----•-- i # J . Seeps it: Distance to nearest well- --- _Distaricte from J1.----- Lance to nearest lot line____:--- Limn materia -..Size: Diamete��l._ -----Depth_..G J------------ - p• ----- „ ,�• t» R� Cesspool: DstanceNumber ofromsnearest well__--__•.__g_.._.Distance from foundstion______________'_'';�.Lmmg material__._-----------.._. ______ ____. Size: Diameter------------------ - --�--Depth--------------------------�� ----------t'#'-`t Liquich Capacity - gals. Privy: Distance from nearest well------- Distance, from nearesf.building.`___..._________------ ------- --- T;-, ❑ Distance to nearest lot line: A------------ ----- ----- --=--"11 --------------- ------- --- - ,� ,�- p --- Remodeling and/or repairing (describe):. = ` = ^~�' P '�' ------------- i ' M --- - -----------------------•------------ ---------------------- --•------------- t - -----------�------ ---------------------------------------------------- F --- - - -•- ---- ---- -- - ------------ ---------- ------- --------------- _ :. F..__--------------.__-_-.-------_.__-_-._-_--a-._-_--__-_-----_-___.___..____ 3 I hereby cer f +fiat I have preparled 4his application and +ha+ the work will be done in accordance wi#h Sin Joaquin County ordinances, Sta ws, and sand regulations of; the San Joaquin Local Health District. {_ _-_---(Owner and/or Contractor) t C.S. ----------------------------- [Signed}----•--- - �-�•. ------ r -------------------- ------------ By: ---- -- (Title]_ `:. By:--•--------- y (Plot plan, showing size o ot, loca+ion of s s+grin mr•ela tom ,swells, bu dings,a+c„ an be placedon'rverse side). lr F EP RTME USE LY APPLICATION ACCEPTED BY - ------- ------ REVIEWED BY--- ------------=------ `--------_ --•---- - ------ --- ------- DATE---- -.:. �-- - -- % "` ----- ---------- DATE A) BUILDING PERMIT ISSUED = Iterations and/or recommendations------ ----- ------------- ---- - • - ---- --------- -- a r: t. - - �' ------ --------------- ..� -------• ---- Date---- - -- - - --------------- �,,�INAL INSPECTION BY:.. ----- -�--�------/ --------------- _ - _- -------_--- --- SAN JOAQUIN LOCAL HEALTH DISTRICT r - 1 1601 E.Hazelton Ave. 300 west Oak Street 124 Sycamore Street 205 West 9th Street +. 5tocklon,California Lodi,California Manteca,California Tracy,California ES 9 RCViSED 13.59 3M 3-•63 F.P.CO.