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FOR OFFICE USE: t ; ----------------_----___-------------.---------------- APPLICATION FOR SXNITA71ON PERMIT Permit No. __.�01__7,l l ----------- ------ ------------------------ ------------- (Complete in Duplicate) -------- -_ I This Permit Expires 1 Year From Date Issued 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 a�plication is made in compliance with County Ordinance No. 549. JOB DDRESS AND LOCATION--------- Owner s Name------------ / !f ------------------Qf �� ---- ----- ------- ------------------- --------- ---- Phone_-3;' Addr ess------------------------- _.� Contrictor's Name--- _,_- -r.__.- -- -- ® S_�., '.t4� __ Phone-' � f467 Installation will serve: Residence Apartment House E- Comme tial ❑ Trailer Court E] Motel [3 Other E]Number of living units: __f_"+_ Number of bedrooms _.3_ Number of baths 2--- Lot size /��Cr",�i7-�--.___-___--_________________ Water Supply: Public system [-I 1 Community system ❑ Private 2L Depth to Water Tablet. Char�ter of soil to a depth of 3i feet: Sand E] Gravel E] Sandy Loam E] Clay Loam,�C Clay El Adobe El Hardpan El Previous Application Made: (If yes,date---------------- ---) No JZ New Construction: Yes ❑ No f�l FHA/VA: Yes ❑ Nom TYPE OOF INSTALLATION AND iSPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t p foundation--------------------Material----•----------------------------- ----------- p❑1 Tank: No.of�com artme ts---weEf--•---- ------Size e-from -------------Liquid depth--------------------------Capacity----------------------- Septic Dis o£ } F p gal Field: Distance from nearest well--.l��!_.._Distance from foundation__{in.��`.F.....Distance to nearest lot line_,�6%- es-------- __.. .---Length of each line__ J'-_ .Width of trench��_-------------- Type _ ___________ �7 Number of IlnmateriaL,S . /--- ---------------- W )/ - � � . length -.`�' See e Pit: DYpancef tloen f �� Depth of filter materiaET�al_ � s Seep ig nearest wet_-' Distance fr undation----IL9__ D' fa nke to nearest lot line- Number of pits-- /__.______._Lining material- Size: Diameter_ ±? De th_.__..�_-__-.____...____- Cess --------- Cesspool: Distance from nearest well•__ I _.,Distance from foundation.-------------- _ Lining�naterial-------------------------------------- Size: _ ____... _.____. _._________. t p Size: :p Diameterr_---.__._ id, --------.-----------�--�- Depth---------------------- ------ --- -------._.Ligw ,,�CapacitY----------=��`�------ ----gals. .3 nearest well------- ----------------------------------------Distance from nearestwilding--__--------------/------------------- PrryY-❑I Disfance to Barest lot line-- ) - = ) ----------7------------------- Q : Remodeling and/or repairing (describe):----- --- .. �7^.Q---•-`E - -, - '.l/y.�a_•. --- ---------------------------- -- 1 / ------------------ = -------------------- - )----------------------------------- --------- i '---------- ----------------------- --------------------•------ -- -------------------- ------------------------------- 1 C 1=hereb certlf that I have prepared this application and thathe woik`wlllb`e#done in accordance with San Joaquin County j ordinances, State laws, nd rules -a lations of the San Joa uin L ca Ith District. d (Signed).........*sizeof ----'--- , ner andr ContractorSY=------ : �sysfem -- - -------r--- .--.-------------------(Plot plan, shots+' relation towells, buildings, etc., can be placed on reverse�side)A I FOR DEPARTMENT USE ONLY �► APPLICATION ACCEPTED BY------------------------- --------------- --------------------------------------- ;-ATE------- r r REVIEWED --------------------------- --- -- ------- --------------------------------------------------- ---------- DATE------- ,...:., .. ------------------------------------------- BUILDING PERM. i'f"I�'SSUED _ ---- ATE----------1 Alterations and/or'recommendations:___.__.._ - ------- ________________ •------ 1 .. ---- - ----------•--------------- ---- # ---------------------------- -------------------- --------- 4. _ `s FINAL INSPECTION BY:................. Date------------------�I�lG SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Ha:eiton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street ti Stockton,California •-Lodi, California Manteca, California Tracy,California F.P.0 O. 4��