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----------------- ------ <br /> " - <br /> --------------------------------------------------- LIGATION FOR SANII`A7[ON PEF`�T - Permit-No: �11r..-. ... <br /> . � ��: , .� <br /> --------------------------------------------------------- (Complete in Duplicate) i <br /> This Permit Expires 3 Year From Date Iss1� ie Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and in w hetes d. <br /> This app ica ion is made in compliance with County Ordinance No. 549.. p/J f rl <br /> JOB ADDRESS AN AION.`_ .__: zr�c )-e <br /> � �__ .-?fh---_-�_._�i ___�: ....... L__.��� <br /> ----- �f <br /> Owner's Nam ---- - --•---- - ----�- --------- --�----------••--- --•-------•-•--------------- - --- ----. PB'one------------- <br /> Address------------••--- ----- --- ------ <br /> -------�------- =----r1,T—.!Z---------------------------------- ---- ----------- ------------------------------------------ <br /> Contractor's Name--- --•--------• ------ ------( N -�---------- ---= L--`-z-*- - ----------------- Phone.........................--•------- <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ TrailerCourt ❑ Motel ❑ Other ❑ <br /> Number of living units: __/-__ Number of bedrooms _�Number of aths -7-----Lot size ____ <br /> Water Supply: Public system ❑ Commuriity system ❑ Private Depth to Water Table __._____ t. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan ❑ <br /> Previous Application Made: (If yes,date............._._-_.) No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 240 feet.) <br /> Septic Tank: Distance from nearest well-__--_-_--_--__Distance from foundation--------------------Material_------------------------_._..____._-_.________- <br /> ❑ No. of compartments---------•----------------Size.-.------------•---------------•Liquid dep. h------- ------Capacity------- -�n--- <br /> Dispos Field: Distance from nearest well---._ 4........Distance from foundation____ _ ________Distance to nearest lot line_ --___.______ <br /> Number of lines______________ Length of each line__-__�_: ---�r ___.Width of trench____"_ ________________-.- <br /> Type of filter material--------- --------Depth of filter materia-----t___ ..........Total length------- {-------------?_____________ (� <br /> See a it: Distance to nearest ell----_4Qe!--Distance fr oundation____ ___ .�_.Distance,to nearest Iqt <br /> p <br /> �r Ld'� <br /> Number of pits___._ _Lining material._.__ _____.Size: Diameter_____,- .______.Depth_________________________._____. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------____________- <br /> ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. <br /> 1 Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-_--_-_-_____--_-_-__,_.____:__._._-_-. <br /> ❑ Distance to nearest lot line--------- --------------------------------------------------------------••------------------------------------------------------------------- <br /> Remodeliiig and/or repairing (describe ._______ . <br /> .-----••-------- ---••---------•--------------------=--------------"----------------------•---•----------•-----------------------------------------------•--------------------------------------- <br /> ------------=-----------------------------------=------------------- ----•------------ -------------------------------------------------------------- -------------- <br /> -----------------------•-----------------------•--=----•------------------•-----•----•--------------------------------------....------•--...-.._--------------------------------•--------------------------------------- <br /> I hereby certify t. t I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State ws, a d rules and 0ealions. of San Joaquin Local Health District. <br /> f <br /> {Signed} -------------------- a and/or SContractor) <br /> gY= ------------------------------_ (Title) --------------- ------ <br /> (Plot plan, showing size of lot, location of system in re at in to wells uildings, etc., can be placed on reverse side). <br /> -FDR DEPARTMENT USE ONLY z <br /> � <br /> APPLICATION ACCEPBY- . - r_ :_,---------------------------------------------------• DATE------ =-�7- ��-�--- ------------------. 1 <br /> REVIEWEDBY � T/j.7' -----------------------------"---------------------i--------------------------------------------------,- DATE-----/ -`--r------------------ <br /> BUILDING <br /> J----.._..--BUILDING PERMIT ISSUED------------------------------------------ <br /> -- <br /> ---- ---- ------------------- DATE------------------------------------------------------------ <br /> Alterations <br /> ----------------------------- -------- <br /> Alterations and/or recommendations:____________________ --"--- ---------------------------I--------------------------------- <br /> ----------------------- ­-------------------------;­­---------- <br /> -_-.--.-_.------------------------..._....---------------------•-----.....--------- ---------•--------------------------------------••----••--•---- -- .... •----•-------------------------- ----------------------- <br /> s <br /> F <br /> FINAL INSPECTION BY:15 <br /> h"rs '= d` Date <br /> ' n�� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1501 E.Hazelfon Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> - E5 9 REVISED 8-59 3M 3-163 F.P.c O. <br />