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R OFFICE SE: A 2"..' Z/.-I Y� ---------------,- -.-----:------------------------------. APPLICATION Ff7R= A` iA710N PERMIT Permit No. .--Zj_. •-- •-. -- ------------ - - -- ------------------------------- (Complete in Duplicate) �1.1.3----=---------------- This Permit Ex ires 1 Year From Date IssuedDate 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. &I � JOB'ADDRESS LOCATION-----��._[p-L.....2_�------+--F-j-�-r- —•----- -------------------------------•-----------------------------------•-• Owner's Name------ Vic_------ - ............... = ------= =r." `-: __ .._..--------- Phone--- 7._rk.13 Address............... - Contractor's Name I � .%------------- Phone----------------------------------- Installation will serve: Residence Q Apartment House ❑ CommercialElTrailer Cou'rf'❑ Motel ❑ Other ❑ Number of living units: __1..__ Number of bedrooms ._ _ Number of baths Lot size __�o----______________________ Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table _40 ft. Character of soil to a depth of 3 feet:` Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Q__Hard7-0-©1 Previous Application Made: {If yes,date--------_'_ami___.-) No �� New Construction: Yes [moo ❑ FHA/VA: Yes ❑ � TYPE OF INSTALLATION AND SPECIFICATIONS.— 9� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` Septic Tank-y Distance from nearest well_________________Distance from foundation....................Material_______________-_____-------------------.___.-__. ❑ q No. of compartments--------------------------Size--------------------------------Liquid depth__..... ------------Capacity....................... Disposal Field: 1 fir/ Distance from neareWweli_--:Distance from foundation.__J6_ ..... Distance to nearest lot line 5aA� Number of lines----------/-------------4---------Length•of each line-----5{-O-`------------.Width of trench---� -��--------•-•------- Type of filter material.-'� ��{_____Depth of filter material......t i_�r____..Total length---------$a-/.................... Seepage Pit: Distance to nearest well------------ ___. ---Distance from foundation------_____________.Distance to nearest lot line__._.___._..__... ❑ Number of'pits----------------------Lining material..'--------------------Size: Diameter----------------------.Depth---------------.................. Cesspool: Distance from nearest well------- from foundation____________________Lining material_._.___.....___..._._................ ❑ Size: Diame'er---------- ----------------- ------Depth-----------------------------------------------------Liquid Capacity----------------------------gals. S Privy: Distance from nearest well--------------------------------------------------Distance from nearest building_____-_-_______________.__._______.___._. rn ❑ Distance to;nearest lot line------------•------------------- ------------ --•---•_..._. -------------------------------------------------------------•-•------------- Remodeling ---------•-R odeling and/or repairing (describe): -------------• --------------------•-----------•--------------•-----•---....------•-------------••----•-----.-•-------•---- -------••---------------------------..................... �.. I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) :• '----------------------------------------------------------- -------•- •------------ ---(Owner and/or Contractor) ---- -- ...---•- --...---- . -- - ----------¢ ---------------------------------------(Title)------------------- ----- (Plot plan, showing size of lot, ion of system in relation to'welis, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- f ---------------------------------------------- DATE....I-------7._...43-------------------------- REVIEWEDBY................-------- ----- -------------------------------------- Z----------•-------•-•------------- DATE------------------••----------- BUILDING.PERMIT.ISSUED----------------------------------------------------------------------------------------------------- DATE-----------------------....---------------------------------- Alterations and/or recommendations:-------------- ------------------------------------------------------------------------------------------•------------•-...----------------------------------- ------------------------------------------------•--------- -------------------------------------•------------------------------------------•---•---•-••---•---------------------------- ----------- -- - ----•.....................••-•--••---------......------- -----------•------------------------------------------•- -•-••--•--••---------------- --•----------------------•---• -------------------- ---•-----------------------------• .-------•------------•------------------------------------•----- -----------............------------------------------------------------------------------------------------------------ ------------------------------------- ------------------------------------------------•------•-------------------------------------------------------------------------------------------•- --------------------------------- FINAL INSPECTION BY:----4-1...... - C --------------- Date_...------- ? /- �?/ �,-_ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 134 Sycamore Street 205 West 9th Street Stockton,California Lodi,California ��,�_. Manteca,California Tracy,California ES 9 REVISED 5-59 ZM 5-61 ATLAS