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� /FUROFFICE-U�� -- --- - -.------ p------__ __________-__.___.._.------------ APPLICATION FOR SAN ITATIOW PERMIT Permit No. Q _.__-_ .. r (Complete in Duplicate) S ----------------------- This permit Ex fres 1 Year From Date Issued Date Issued - _---- �_. � Applica#ion 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 LOC -. -------------------- --------------------- ----------------------------- Owner s Name-------------------- - --- u�� P ------------- Address .- Add res s------------------- ------ ------ --------- ----- ---- . 4 F u --- / .. ------- .ate ------ Contractor's Name - ----------------------- ----------=--- ----------- --- Phone------------------•------------- Installation will serve: Residence Apartment House Commercial ❑ f P ❑ ❑ Trailer Court ❑ Motel ❑ Other %.. ��j Number of livings: _, -� ber of bedrooms -��*Iumber of baths --�size _--_-/V_ ____-_ - Water Supply: Public system [) Community system ❑ Private Depth to Water Table -6 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ y Previous Application Made: (If yes,d4te------------.-------.1 No ❑ New Construction: Yes ❑ NFHA/VA: Y,&❑ N TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) T� Septic Tank: Distance from nearest well--J__-_-----_Distance from foundation-_- !-.-__._ Materi�__e-I-Iex("r✓-c_,�T--- - No, of compartmenfs------------- ,'r�, "Sizey Liq id depth -------------- Capacity Dispo a Field: Distance from nearest well- '__.._Distance from foundation--- U---_-Distance to nearest lot line------- Number of lines'.-,------- ........ ---Length of each line------------ Width of french.-------,1 --------------- ----- Type of filter materia!____,_ r ---Depth of filter material___-- Total length------ : r----------_--•---- Seepa e Pit: Distance to nearest well..__ -_ t9�---Distance from foundation'rr--------------- i�tance nealot line---- Number of pifs---- Lining material__-. _.� .Size: Diameter__�J- ' ------� i . ...---Dept h - /�---�------- ---- Cesspo I: Distance from nearest wet!_________________Distance from foundation-_--_-_..._.--__---.Lining material--.------- .___.__.-------_-_.---. r ❑ b Size: Diameter----------------- ---- ----Depth-----------:- ------------------------ -------------Liquid Capacity-------------- _ gals. ,.,,, it W Privy: Distance from nearest jwelf---_-----___it--------------------- -- -------Distance from nearest'buildin ------------------ r i..line- ------------- . ❑ Distance to nearest got:line----------- "` --- -------------------- ---- - ------------------------------------------------------------------------- ----------- . Remodeling and/or repai6ngf(describe):* _. .--P fib - -_-__.-C?,rJ' �_ - - ------------•-------.-•----•--------------------- •-------- } ---------------------- ----------------------------------------------------------------------------------------------s-------------------------------------------------------------- ----------------------------------- - ----------------------- ----------------------------------------------------------------------------------------------- .-_--.-.------- I hereby certify that I have prepared this application and fhat the work will be done in accordance with San Joaquin County ordinances, to laws, and rules andlregulations of the San Joaquin Local Health District. (Signed) �.�"� ! ----- = -------- ------------------------------ ----T---------•-------- - - -- -.(Owner and/or Contractorl BY ----- 1-------------------------------------- ----------------------------------------------------------------------(Title)---------- ----------------------------- ---------------- -- i (Plot plan, sho ing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). t- EPARTMENT USE ONLY l APPLICATION ACCEPTED BY , ------------- ------- - -------------------------------------- DATE-------fI REVIEWED BY------ # _4--------------------------- -- = --- --------- DATE BUILDING PERMIT ISSUED--------------- ------ ------------------------------------------------------------------ ------ DATE----- Alterations and/o 'recommendations:- -------------------------__"------------_- 66 �a , --; f - ------------------------- -------- .-:-. __7 . _--e fA----------- 1 rr-r- c ✓ a -c �'l�c�u ----- - --------moo r_ .._ e - ` f INAL IN P / `` SECTION BY: - --------------- Date----- - # AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodir California Manteca,California Tracy,California r.a.co. -_