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FOR OFFICE USE: ------------------ - --------yW/4-1------- �� - I APPLICATION FORaSAiPiWATION PERMIT Permit No. .9-a............. - ------ -- ------�-tom-- - ---'-------- -- --------------- ---------------------I -- -------------- (Complete in Dup icafe) Date Issued -------------------- ----------------------- 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.... l ? e-------- --------------- ---- ------------------------------------------------------------------------------------------- Owner's Name--- 1� .... � tl �- ----------------- --------' ------------------------- . Phone ...----------==---------•-------- Address-- -li -------- ------- ----------------------------I--•--------------------------------------------------------------.------------------------------------- Contractor's Name--------i✓J/ �,� y �,t'" ---------------------------- ----- ---------------------------------- Phone Installation will serve: Residence @��Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._f_-- Number of bedrooms - _ Number of baths -/___ Lot size ll-�r l��ll.---------__------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 494 ft. ' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g3--Rardpan ❑ Previous Application Made: (If yes,date____________________) No [L]---New Construction: Yes ❑ No DOHA/VA: Yes ❑ No gj- 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-----------------Distance from foundation------------------Material.....-..___-_-_-.-.--------._-_------------------ l� �!f No. of compar#ments--------------------- ----Size--------------------------------Liquid depth-------------------------Capacity--•-------------------- I Disposal/Field: Distance from nearest wet!____`_- .Distance from foundation.._g ----....Distance to nearest lot line-&L/------ Number of lines------l--------------------------Length of each line.. l------------------Width of french--A--------------------- --------- f .✓ _ Type of filter material_/.�/ -CP.,-1�..Depth of filter maferial....�X -----.Total length-_-`�.,...... _.__._._------_--_ S It Sewage Pit- Distance to nearest well___________ ________Distance from fouundation__�fl.---------.Distance to nearest lot line. ----- �1 ��[,,klJ�w <'`'�r Number of pits------------------Lining material_.�[�-0��/ ...Size: Diameter__._ Cesspool: F Distance from Inearest well_--- -----------Distance.from foundation--------------------Lining material___________...._-_._______--..-...._ ❑ Size: Diameter----------------- -- -----------------Depth---------;_--------------- -------------------------Liquid Capacity----------------------------gals. -----------------Distance from neares I Privy: Distance from*nearest well ------------ --------- -- - t building-----------------------------------•- ------------- ❑ Distance to nearest lot line------------------------------------s ---------------------------------------------- Remodeling and/or repairing (describe) - r ------------------------------------------------------- I -----------------------------.---. ------------------------------- ------------------------•---------------------------•----------------- -------------------- I hereby certify that I haveprepared 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) ;- Yk - PMMD rd/or Contractor) BY -- f� ` =_ (Title} E�1 � (Plot plan, showing size of lot, location of systemation to wells, buildings, etc., can be placed on reverse side). # R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ ` -- --- - -------------- ------- ------ ------------------- ---------------- DATE------ - .1.- � Ej---------------------- REVIEWEDBY------------------------- ----------- -- --- - - -------------- -------------------------------------------------------- DATE------- ----------------------------- --------------- --- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations- � -- ------------ - '- ---------------- -•-• ------ ------------------------- -- ------- ---------------------------------- ' ----------- - -------------- -------- ---- ------------------------------ ------ --------------------------- --------------------------------------------- ------------- ---- - -- -•----------------------------------------------- FINAL INSPECTION BY:_____'.. - JC ;� ------------- Date----- --- G -------------- S N J0 QUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,C01001rnia Lodi,California Manteca,California Tracy,California F.P.CO.