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FOR OFFICE USE:"`--`- t - ------ --------------------- RMITPermit No. ------------------- --------------------------------- -- (Complete in Duplicate) Date Issued ---------------------------------- ------------____ wThis Permit Expires 1 Year From Date Issued A, r 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein Esc This application its made in complia ce with County Ordinance No. 549. e CR JOB ADDRESS AND LOCAT N __ _g9N_D__- AV_--�----- Owner's Name---------------- -------- F16,-y,-_ S------------------------------ --------------- ---------- Phone--------------------•-----------•--- Address ._-_:_ --j C .----------1�� -f7------------- F /9:` -----------------------•---------- ------ Contractor s Name ---------------- - --- Phone I �. Installation will serve 1 ResideIt ce'Er Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /--- Number of bedrooms __�-Number of baths -_ ____ Lot size ___ __1 ---- rJ�--------------------- Water Supply: Public system~❑ Community.system E] Private RT"'Depth.,to Water Table ®ft. Character of soil to a depth of 3 feet: Sand Gravel E]- Sandy Loam E] Clay Loam ❑ !Clay E] Adobe ❑ Hardpan ❑ Previous Application Made: (If yes,date--------------------) Nok3--�'New Construction: Yes ❑ No [AHA/VA:.Yes ❑ No [� ;- - --! - YPE-OF_1NSTALLATION-AND -SPECIFICATIONS: -y= .. ( P P p p available within 200 feet.) No se tic taDD stancesfroml nearest well publicsewer Distance from foundation____________________Mater.ial__._,:..____....__- .Septic Tank. . • 5T1 NIS No. of compartments-- -----.Size-----------------------------:--Liquid dept�--i----------------------Capacity--------------------- Disposal Field: Distance from nearest weli�jr __Distance from foundation__-- ___R_:Distance to nearest lot�line�_____ ___________ STI 14& Number of fines---------- -----------------------Length of each line--- ----------- _ Y,--;Width of trench_ _ �� Type of filter materia4G-}�______Depth of filter material____.__- ________.Total length________ ______________ _______ Seepage Pit: Distance to nearest well_._._---_.:...._____Distance from foundation__________________.Distance to nearest lot line_____._----______ ; ❑ Number of pits Lining material Size:'Diameter1-----------------Depth---- ---------------------- S Cesspool: Distance from nearest well-----------------Distance from'joundafiont.._-_---_..___----Lining material_.-.____....__.._____--_..___._______. I ❑ Size: Diameter------------- ----- --------- -------Depfh-----------------'=---------r----------------- --Liquid Capacity---------------------------gals. , c ' Priv Distance from nearest well-____ ---------------- ------- Distence from nearest building------------------------------------------- -______ ______ € Distance to nearest lot line____.-_- ' .-.-_._ ----------- !- �*�' ! ------------- �� I .� Remodeling and/or repairii.g (describe):--- -------- ----- ------------------------•------ =---------------------- ---•--------------------------------------------- -------------------------------------------r -------------------- --------------------------------- ----------------------------------------------------1-'•---------------------------------- 4 --------------------------------4 . -1W'$ rk- -------.-•-••-------------- ---------------------- ------------------------------------ --------- --------- --- ------------------------------- --------------------- 1 hereby certify .t t e_p epar'ed this application and that the work will be done in accordance with San Joaquin County ordinances, St to I rules n4)regulations of the;San Joaquin.Local Health,.District. (Signe - _i'(�` � ----- - - )O and/orContractor) (Owner a By=---------------------------------------- -- --------------------------------- -------------------------------------------- ------------- -- ---- --- e_ (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY '.APPLICATION ACCEPTED BY------ -------------------- DATE-----------S_:7�_Z REVIEWEDBY----------------------------------- _ ------------- ------------ DATE------------------------------------- ----_---------------- BUILDINGPERMIT ISSUED--------------- --------------------------------------------:------------------------------------- DATE---------------------- --------------------- --------- - - - - --------------- � Alterations and/or recorrimend8tions---------=------------ - ---------------- -=---=------- -- -m---•--------• ----------•----- •-------•----------'------- <- �, t 1 t ' 1 ; „e _ , M. . - -- ---- - -- ----------- ---E ------ ---------------- , _ � Date----------------- ---------------------- FINAL INSPECTION S SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Ho:elton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California