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t No. APPLICATvi#I FOR NITATION PERMIT Permi Complete in Duplicate) Date issued -------1.?nkA1!7 A ic, for"i.r. App icaf ion is hereby made to the San Joaquin Local Health District f a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 54Q. 'S S -- ----- - - --- - -------- 4---- --- JOB ADDRESS A OCA ON-- - - --- ----- X Name �5-.7,/Cq Owner ... ---------- ----- ----- - ------------------- ---------------- ---- Phone- -- -- --- -------- --- --------- Address--------------- -------- -------- ----------------------- - ------- ---- ----- --------------------------------------------------- ---- - Contractor's Name___---_-_ ------ ------------------------------------------------------------------- Phone _7 --- - - -- -------- Installation will serve: Residence, -Apartment House ❑ Commercial ❑ Trailer. Court El Motel Other El Number of living unitsNumber bedroomi--2—, Number of baths ---/-- Lot size of - --a--?- ------------------- Water Supply: Public system El Commu6itY system El Private E] Depth to Water Table��_ ft. Character of soil to a depth of 3 feet:- Sand E] Gravel El Sandy Loam [:] Clay Loam E] Clay E] Adobe Hardpan E] Previous Application Made: Yes ❑ N New Construction: Yes No E] ' FHA/VA: Yes El Nq,� TYPE OF -INSTALLATION AND SPECIFICATIONS: --,,- + '�°''(No septic tank or cesspool permitted if public'sewer is available within-200 feet.) Septic anik: Distance from nearest,.well----------------- Distande from foundation-------------------Material------- ------------------------------------ No. of compartments--------------------- ------------------------- ----Size------- Liquid depth--------------------------Capacity-:---------------_----- 131spo I ield:--' Distance from nearest 'well----------------�Distance f rorn-Jounclation------------- ------Distance to nearest lot-line_____._:_______ r Number ine--------------- Number of lutes-----'------------------------------Length of each line------------------------------Width of"frehch----------------------------------- Type of filter material ..-Depth of filter material----------------- -Total length_'--___-.---_._____----------------------- Seep ge Pit: Distance to nearest --------Distance ��oafion -.Distance to nearest ]of ------- Number of pits--i./---------------Lining material_,,e --- - ---..Size: `Dia�e4fer------f?eX......Depth. -----� -------- Cesspool: Di5fance from nearest well------- ell----------------- istce from foundation------------------ Lining material------------------------ -------- ❑ Size: Diam�'eer----I---------- - --------------------Di Depth--------------------------------- - - ----Liquid Capacity-------------- - ..--gals. Privy: Distance from nearest welt_ ____.._ ------- --------.,-Distance from 'nearest building-_-, ------------ - .... F1 _-Dil ance-fo-neare"S� lof,llne------------------------------------------------- ------------------------------------------------------------------------------------------ of—re ------ k It : �pairirg (describe):_�__A Remodel _Z ---------- ---------- ------------ -------- ------------------------------ ------------ ----------- - - ------------I-----------------!-------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------- Y�\ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- I hereby certify that I have prebared this application and that the work will be done in accordance with-San Joaquin County ordinances, State laws and rule a regulatiops of e Sa Joaquin Local Health Districf.= (Signed)--- ----- ------------- ---------------------------- (OWrker..pnd/or Contractor) I-- ----- ------ -- - - ------------- -------- d:�� ----------------f-------- ----------- ---------------- ------- -------------- i By:-------- -----------------(Title ........�e)j. location system in-relation to wells, buildings, etc., can 66 placed on revers d (Plot-plan. showing size of of, I tion i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 'BY-------------------------- -------------------------- ---------------------------------------- DATE---------------- -------------------------- REVIEWED BY I --- m --- ------ ---------------------------------------------------- -- DATE------------- --------------- =-------------- BUILDINGPERMIT ISSUED--------------- ------------ -- ----- --------------- ------------------------- ------------------ DATE---------------q_----------------------------------------- Alterations arid/or recommendations: --ions-.-!----------- --- --- -- ------ -------------------------------- ------------------------------------ ------------------------------------------------- - ----------------------------------------------------- ----------- 47 --------�7----- -Ap- ----- ...... _-re -------------------- --------------------------------------- -------- ------ ------ ------------------------------------------------------------- --------------- -------- --------------- 7 ---------------------------------- -0-8---------- ...... ---- -- ------ ---------------------- 1. -ic— OA�ArrV ---------------:,;Z�------------- - - -------------------------------------------------------------------- --- ----- ---------------------------------- ------- -------- --------------------------------------------------------------- fi FINAL INSPECTION BYDate........ 1------3 - ------------------- ---------------------------- - -------- ---- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy. California _j E5-9-2M Revised 1-57 F.P,CO.