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FOROFFICE USE: ^�--- --------------------------------------------------------- ) / ------------------------------------------------ -------- APPLICATION FOR �S NITATION PERMIT Permit No. ._,[_.74S ------------------- ------------------------------------- (Complete in Duplicate) This Permit Expires 1 Year From Date Issued Date Issued __�!___l---- Application is hereby made to the San Joaquin Local Health District for a permit to construct and insFall the work herein described. This application is made in compliance with County Ordinance No. 549, JOB ADDRESS AND LOCATION:f , f - �� ---------------- - - ------------ --- Owner'"s Name ..tZ � ------------- = - Phone.._ ----------- ---------------------- Address_. ------------------------------ Contractor's Name----------•-----"4 -`= --••----------------•------ Phone-------------- .--- - Installation will serve: Residence J Apartment House Commercial ❑ I p ❑ ❑ Trailer Cour{ ❑ Motel ❑ Other Number of living units: __.j_.. Number of bedrooms _3-- Number of baths __-'):Lot size .�_ 0-_--- _ - Water Supply: Public system ❑ Community system 0 Private �h to Water Table -1,' ft. Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam :Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: (If yes;date_:--------------------J N New Construction: Yes�o E] FHA/VA: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept Tank: Distance from nearest we4___50_____Distancev from fou �}dation-------ID......Mat rial___- No; of compartments-- � _ - __________ Size_ 1�--� ( _..Li uid de thacit .t:. Ca �� q i? � p Y c1-7 c>_. Disposal Field: Distance from nearest_well-n.5-�------,Distance from foundation____ ____.Distance to nearest lot ❑ Number of lines„_--_:� -----------------Length of each lingjfo__ -1- _`!. °-Width of french__ ------------•-- Type of filter rndferial__5-_�`f��r.f�epth of filter material_---._ _ _-_ Total length_________ _%-!- _____________________ Seepage Pit: Distance to nearest well.---------------------Distance from foundation---..---------------Distance to nearest lot line------------------ I ❑ Number of pits::,)__________________Lining material-----------------------Size: Diameter---._----._______ Depth-. --------- -------- Cesspool: Distance frarrl «nearest well----------------- from foundation---_-----------------Lining material------------------------------- ❑ Size: Diarnefer:_..)---------------------- Depth----- - ----- - ------Liquid Capacity ---- -- ----gals. .}� ....rte-;.,,..,,,._-. . � , '' ' =Pr . Y-- ;.r<-�' - v y: Distance from nearestll _-____: _.__ - -.=rr- -} - . ----- ------- --- ---- ---- -Distance fromm' nearest building------------------ ---------------------' >� ❑ Distance to near4s t.lot = _ l_ire�_j_-�_1._---------- Remodeling' �/or repairing (descril ..0_-l_--------------- --••------- - : v = --- - --• i - ��-------------------� --- - a - ----------------------------------- ------------------------------------- - I`hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County f ordinances, State laws, and rules and r gulations of the San Joaquin Local Health District. (Signed)--- s -5�??--------- -- ---- �-'eT-�---.��-- � f / - (Owner and/or Contractor) Y ---- --,-- -,i -- ------------------------- -----(Title)---------------------- ----------- ........... (Piot plan, showing si of lot, location of s' tem in relation to wells,.buildings, etc., can be placed on reverse side). �p FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- ------ -------------------- ----------------------------------- J_0 - - --------------------- DATE--------------- -- --- - 2�` I REVIEWED BY ----- ----------------------- -----------r -- C- DATE BUILDING PERMIT ISSUED - ---- -------- ---------- DATE---------------------- ----- - -- ------•- - Alterations and/or recommendations:!------------------------------------------------------------------------ - ---------------------- -----•-------- --------------------- ------------------- •-------- -------------------------------------- ---------------7----------------------------------------I——------------ ----- t -------------------------°--- --- •--------•--------)-- - ----------------=---- --- --- •------------------ ------... ------------ ---- - ------------------------ f� _ �. �{_ J FINAL INSPECTION BY:__.___________________ -- -- . - C� � ' Date ---------------------------------------- f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hasallon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,Colifornia ES 9 REVISED t3-59 3M 3-'63 F.P.CC.