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FOROFFICE USE: r. APPLICATION`FOR-5A'NITATION-PERMIT —Permit No.�- Com late in Du Lcate ------------------------- --- ------------------- ------ p p ' E - ----w------4:...... .. .�--..� -- _.r 6 Date Issued<3 _ _/ 'This Permit Expires 1 Year From bate Issueda 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 AW LOCATION_:___ZJ_ el ----- -- Address__Nam�-,-•--�f--/�--�.�______ (.l I�I_._��-_ �t_�--------- ---- - ----------------------------- ---------- Phone__ -•---�------------------------------------ Owner's � f , L St�41�-----=- ----- - Contractors Name f+/ l -------------- Phone.k a-- Installation will serve: '.Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote! ❑ Other ❑ Number of livAllunits- Number of bedrooms _3. Number of baths __t__ Lot size -4 !` ___- __Ir•_ ate_------->---__.---_ Water Supply:' Public:system ( Community system ❑ Private 0 . Depth to Water Table _______ ft. Character of soil to a delpfh of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 4 Clay Loam ❑ Clay E❑ Adobe ❑ Hardpan ❑ Previus Application Made: (If yes,date----------_--------- No New Construction: Yes ❑ No ❑ FHA/VA: Yes.❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r SeptiE c Tank- Distance from nearest well-___..___ __-_Distance from foundation------------_-------Material ----- No.of compartments--------------------------Size...---------- _ ------------------Liquid depth.-------------------------Capacity ------I------ ' Disp❑�osai Field- Distance from nearest well 0l* ` A-- .F -Distance from foundation�/_�___. distance to nearest lot line �r..�_'____..___,.t-� Number of lines-_` ---------f----------- Length of each line-------a_Tf4_f-_---------Width of trench._--�- ----------- ---- --- T e of-filter�materiai. 4'/ !�-/�aepth of filter material__--- 4711 length____4----�__________________ Yp v -- ------- _ ` r See a e Pit Distance to nearest well- 6.71 _Distance r found ion___ istanc to nearest lot l�------I---------- W p:9 C Number of pits:___L___- _-____Lining materia __- [-Pf�" -S e: Diametr;rDepth__ - r - ------------------ Cesspool: i Distance-from noarest well_______--_._____Distance oundation----__-- --`_ Lining material_-.._________________r- F ❑ Size: Diameter-----I Depth # -----Liquid Capacity------------------ k--- gals.�� Privy Distance from nearest well---------------------------------______________ _Distance from nearest building-------------------------- ____--__.--.__El ._. I Distance to ne'a`rest lot line_______________________________ ___ A Remodelin and or 're irin escribe'' :a ifs_ '� I r ate - f ___ ___------ ---------------------------- __________________f ____________: _ -------------------------_ _ ----------- : -I I ` , T � - I hereby certify:tfiaf l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St laws, and:rules and re ulations of the San Joaquin Local Health District. I r i (Signed)----•- ------ � -- v. i ---------(Owner Contractor) r� By:--•------------- .. --- ........ ` = t (Plot plan, showing size of,lot,_location'of-system--in:relation'fo-wells,;buildings, etc., can-be-placed-on-reverse side). —.1 11 'f ' V. FOR DEPARTMENT USE ONLY DATE / APPLICATION ACCEPTED BY REVIEWED BY------------------It -- ----- x=`"`-�` ----------------------------------- --- ==l-__` - •` f ----- ------------ - ---------------------------------------------------------.- DATE--------- BUILDING PERMIT ISSUED - �- ----------------------------------------- -�-------------------- ------ DATE-- ------- -'- i_ F` i 4 a Alterations and/or recommendations o` / �.. �-_ •-� � i _ , , —�� _ F C . ----- ------------------------------------------- ----------------------------c� 5 s I F . - -- ------------------ • -------- , --------------------------- ------------------------------------------ _ ----'---- -------------------------- ` - ----�--------------- - . ----- FINAL-jNSPECTION BY: - -------------- IDat•ae---`j---------------.T_:- ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Fracyr California ES 9 REVISED 4.59 3M 3-'63 F,P.CC. — -�.-