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I- x urrlCt USE: - -- --- � .- .--:__- APPLICATION FOI��SAIN y � ON PERMIT Permit No. --------------------------------------- -------------- (Complete in Duplicate) p� This Permit Ex fres 1 Year From Date Issued Date Issued A lication 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 Ordin ce No. 549. ' JOB ADDRESS AND LOCA N. r Owner's Name--- Address ame--- -- - ---••-- -- -- -�'7rt,1;,Q4 - i tYl�f� lO�..3--- Ph Address___--•----• � . . ------------------- o -------- -- Contrac#or`sNama ` ->_----------------------- Phone-• --- _ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Nu er of bedrooms � Number of baths _/--_ Lot size Water Supply: Public system ___ ommunity system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel n Sandy71_oarn ❑ Clay Loam ❑ Clay ❑ Adobe rdpan ❑ Previous Application Made:` Ilf yes,date-------------------- No ❑ New Construction: Yes ❑ No HA/VA: Yes ❑ No ❑ 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_fA-Q_P4.C*__Distance from foundation__.40 -- ------.....Material-----------•--------- --- No. of compartments_.__-.___:_.________.___Size.S�' _`75��7.,��Li uid cie th_ q P. -67-169---------- Capacity-j-, -Q�-� '� Disposal Field: Distance from nearest weil__W _Distance from foundation.-/' _---Distance to nearest lot line___/_ ..e Number..of lines______ _ _ ----- _ Length of each line___��___11--`-_____.---Width of trench_--ca�4L_�/___ - _Type of filter_ mafierial____ --` j----Depth of,flter.material____._�_ _.Total length____ _Q Seepage Pit: Distance:to nearest well_.KoK.e-------Distance from foundation._ __ .�__. ._.. Distance to nearest lot Number.of pits----I---------------Lining material__&4I -----Size: Diameter---,, it_---_-_De fh__ OQ Cesspool: Distance rommeter nearest well________________Distance from foundation_-..___-_____---___.Lining material:___.____-_________.____--__= r:,.❑ __ ..� Size: Diameter_ �; -_- Depth----------- -- -.Liquid_ Capacity- --------------------------gals. Privy: Disfance from nearest well .__ �" ' _- "~ •~T �, -------------____________________Distance.from.nearest building l .. 9 ❑ Distance lto nearest lo+ line__________________________._.- Remodeling and/or repairing (describe]_---------_ _ --------- ____._ . __ 1 -------------=--•-- -----------------•---- - � I t '------------•J---- --------= _ _ --- ----- P ___________________________________________________._________-.------------ __.._____-_____-_______-_-_.._______-______-______-________-____.___--_________-______-________-____..____._.___-____.-.-_.._---.__. 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 San Joaquin Local Health District. (Signed)-_-- -k. ---1s�g��` •�r j a -zlt�o "�. , I + L! $y:------------ ------- (Title] ontractor] 9 p -------- ------- 1 [Plot plan, showing size of lot, location of system in-relation to IIs, buildin a c., can be laced on reverse-side). FOR DEPARTMENT USE ONLY APPLICATION ACC EPTED $Y r _ • -- '- ---' ------------- -------------- - --------------------------- ---------- DATE ��.--- - REVIEWED BY - '--- ------ BUILDING PERMIT ISSUED - ------------ --------------------- -----------'---------------------------------------- DATE------------------------- ••------- -- Alterations and/or recommendations:----- ---------------------------------- :/-,�_-�_�______-��6�._-_•.�. -------------------------------------------------------- ----------I---------------------------------------- ---- ------ ----- - --- --•--------- FINAL INSPECTION BY:_.__13- _ Date--...... l_Z (T-0- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazellon Ave. 300 West Oak Street 124 Sycamore street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVIGED a-59 3M 3-'63 i.P.ra.