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;?-FOR OFFICE USE: ----------- - -----=--------------------------- -------- A LIC MON- F R 'N TATIOWR ----------------- --------------------------------------- ' I ;ER ermit No. _140--- 5 --------------------------------- - ----- --------------- Com late irDuplicafe) Date Issued ----------------------- -------------------------------- -- ---------- -------- This Permit Expires 1 Year From Date Issued-� I Application is hereby ereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application'is made in compliance with C6u!jfy,, yOrdinance No. 549. AA N ------------------- ---- JOB ADDRESS'AND LOCATION----------------------- -E -------------- ------ANTM-A---------------------- ----------- y1 7� ------------- Phone-------------------------------- !x ------------------------- Owner's Name------- -------------D"-----•--- ---------- ---- --------------------------------------- ................Address------- _-----. ......M .......... Contractor's Name-._--------lew-N V.rx-------------------- --------------------------------------------------- - ------------------------------- Phone.---------------------------------- A Installation will serve: Residence Apajrfme-nT House ❑ Commercial E] Trailer Court ❑ Motel C3 Other El ,bedrooms Number of b L(�t size ----KIP ------------------------- Numberp�jiviqg_units: -- -of-- Number Water Supply: Public system El Community system 0 Private e DZ1?i,\Vater1 Character of soil to a depth of 3 feet: Sand ' �Gravel 0 Sandy Loam E] Clay Loam El Clay 0 Adobe [] Hardpan 0 -- Previous Application Made: (If yes,date ------ ------------) No,011ji" New Constr6c.tion Yes 8"'No E] FHA/VA: Yes E] No4P5- TYPE,OF INSTALLATION AND SPECIFICATIONS: (No septic tank or p'eF_m'i+.fec'1; if-public sewer is available within 200 feet.) nda i Material------------------------------------------------- Septic Tank: Distance fromolear(? stv�,,ell-----------------Distance from"fou t!on-----------4S_ C](6T/fJr-- No. of compart�ants-.---.-' . . "4- Size--.-Size ---------""—-------------�L iquid depth---------- ----- --------Capacity.---------------------- � f d f" A40 Distance to nearest Disposal Field: Distance from nearersf,411,_20.-----Distance from oun at -st lot line---.. .......... X jgT'/Af Number of lines------- ----------Length of each -- -,gr-----.Width;of french6-Y..---0-------------- 4- p Dr-- Type of filter material---- .-Depth of filter material-----/7-_---------Total length-----—--------—--------------------- Seepage Pit: Distance to nearest well------- Distance from foundation--------------------Distance to nearest lot line--.---------.__-_ �n El Number of Dearest --- ---------- -.-Linin g,material-------------- -------Size: Diameter----------------------.Depth----------------------- . epth----------------------- J. Cesspool: Distance from nedrdst well pr-_-_j-------Distance, from foundation--------------------Lining maferial__._,_.----------------------------- 3 nSize: Diameter------- ----------------------{ Depth------ :' ----------------------------------Liquid Capacity----------------------------gal5. Distance from rearest_waIL________-------------- Privy: _ D.!st.ance-from,n ea rest building---------_--__-___-_-___-_------.----.-.- > 4-----------------'------------------- S �j Distance to nearest lot lire- -----------------`----z------------------ ----- ---------------------------------------�1------- El ;1 f /. Remodelingand/or repairing (describe): ----CXT-- -------too--------- -ibe) ------------------- .01Ah--------r-rtj_?_A#-- ----------tr"LIIR,AO_�.4---------------------- ---------------------------•---------------------------- ------------ ------------------------- ------------------ --------------------------------------I---------------------------------------------------------------------lm--------------------- ------------------- ---------------- ------------- -- ----------------------J. o ----------- -------------------------------------------- ------------------------------------------ --------------------------------------------------------------•------------------ 1, : I hereby`_certify that I have prepared this application and that the work-will-.rk-will-be done in.accorda-nce with San Joaquin County ordinances, State laws, and rules and regulations of +he San Joaquin Local Health District. 1 (Signe� -------- -------- -- -- -----_----------------------------------------------- ........ ----(Owner and/or Contractor) ---------------- By�� . ........(Tif le):-----------I------- ---------------------------------------------- -- -------------------------------------- -------------- (Plot plan, sho,�ing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 7 APPLICATION ACCEPTED BY------ Ir ----------------------------------------------------------------- DATE-------- -- -------- REVIEWEDBY------------------------------------- ------ --------------------------------- ------- -------------------------------------- DATE----------------------------------------------------------- BUILDI-NG PER-kd]T'ISSUED------- ------------------------------ -------------------:----------- ---------- Alterationsand/or recommendations:------------------------------- -------------------------------------------------------------------------------------------------------------_----------- w-, ------------ or ----------I-------------------------------- --------------- -1---------- --------------------------------------------- --------------- -—--------------- ------------------------------------------------- C ------------- - -------------- ------------- ------------------------------ 7 ---- -- ------------------------ __j__At_5_rT -,71=.D----------- ------ --------------------- ---------------- ----------------------- ---------- FINAL INSPECTION BY;,.-'---- - -- -------------------------------------------------- Date..---------------- --- ------------ ---------- ......... SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 91h Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED H-59 9M 3-'63 F.P.00.