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31 �o d APPLICATION FOR SAN IiATiON PERMIT Permit No.__!...`....��__.... I0- (Complete in Duplicate) Date Issued----____-- 7-______-• This Permit Expires 1 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. JOB ADDRESS AND LOCATION --_-------------_�Y4.7XI---_.__.___ ___ ._C?�ug1Q%____ _�-a _______ Owner's Name ------------------------------- 1.11�:�1 �_L% ---•------------------------------------------------------- Phone (� - �1.. c�C% Address------------------------ --- - xWQ ..... .1----- — ---------------------------------------------------------------- ---------- 1 dxa6 /Contractor's Name---.^Q1 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 ` r Number of living units: __!____ Nu nber of bedroom-__-- Number of baths-/-.____ Lot size`1--_____X___J_ZLQ_________________ Water Supply: Public system ❑ Community system ❑ Private ®/)Septh to Water Table Y,7 ft. Character of soil to a depth of 3 feet: .Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E]-14-ardpan ❑ Previous Application Made: Yes ❑ No ew Construction: Yes ❑ NoA/VA: Yes ❑ No �-- TYPE OF INSTALLATION AND SPECIFICATIONS: i[No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- v Distance from nearest well----------------- Distance from foundation ------------------- .Material___-.._____...._________.._______.__.__________- ��^� No. of compartments -- --- ----------- -.... Size -------------------------------- 'Liquid de th-------------------------- Caacit Disposal (Field: Distance from nearest well----------------- Distance from foundation -------------------- Distance to nearest lot line _._______________ Number of lines___________________________________ Length of each line ----------------------------- .Width of french ._______________-____________-__ r Type of filter material ___-._______________.__Depth of filter material ----------------------- Total length ________.______-________________--_____-- •/�F—� ` � V `r Seepage P' Distance to nearest well__/QQ_... _......... Distance from foundation__ �__ / Y-------- Distance to nearest lot line-./.Q -------- Number of pits ------ /--------------- Lining material____Size: Diameter____ ._._------- Depth ---- R ST------------------- Cesspool: Distance from nearest well----------------- Distance from foundation ---- ---------------- Lining material -------------------------------------- ❑ Size: Diameter----•--------------------------------- Depth-------------------------------------------------- Liquid Capacity ------------------------_-gals. 1 Privy: Distance from nearest well ------------------------------------------------- from nearest building _______.______._________.______________- ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------ ---' C _ , Remodeling and/or repairing (describe) ------------------y/�C�� +�-�-� �" --•-------•---------------------------------------------------•------------------------------------------------------------------------------•----------------- --------------------------------------------------------- ------ ------------------ --- --------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------- I ------•------------------ -I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules .and. regulations of the=JoaquinLocal.Health District. LA Si ned _________________[Owner and/or Contractor] -- ---By:._----•--------------- .-c�a- :� = y am--------------- -(Title)--- �--------------------- ----- (Plot plan, showing size o of ocation of sys+em 1n relation to wells, but Ings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------------------------------- DATE-------- -------------------- REVIEWEDBY --------------------------- -------------------------------------- I ------------ ---------------------------------------------- DATE----------------------------------------- ----------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------- DATE ------------------------------------------------------ Alterationsand/or recommendations--------------------------------------------------------------------: ------------------------------------------------------------------------------------------- ------------------------------•-----------------------------------------------------------------------------------------------------••---------------------•--•----•------------------------------------------------------ t ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----•- ---.-. ------------- ----- - -------- -- ------ ------------------------•-------•----------------------------------------------------------------------------------------------------------- ------------------------------ FINAL INSPECTION BY:= --•--------------- Date.. .-------------------------------------- ,; SAN JOAQUIN LOCAL HEALTH DISTRICT4 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M Revised 8-'59 F.P.Co. r r