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F R OF-ICE USE: S J ............._: f. APPLICATION FORkS�ANMATION PERMIT Permit No. ...... .......... ___-_____•-,--_.._..._. _ (Complete in Duplicate) t Date issued !.......-.-- --._-. This Permit Expires 1 Year From Date Issued t Applicaiion islhereby made to the Sari Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Or inance No. 549. >t q ................ .................r.._.__._..-_._._... JOB ADDRESS A LO T N.. _ 1 � $ '._ . Phone-------------- ••----:_.._._...... ' a Owner's Name. �r i ........xs.::..:_....:_ ..,,.�._:_... .:� 00 Address........... •. .... -- ---••� - • ---•----•--•--•------------- ----•-•--...------' ---i -...-.-.-.-.-- -.-_-_- .•••-•-•-• . Phone Contractors Name....................... •------•---------------------------------••------- _( �._®1---- r Installation will serve: Residents 0 Apartment House [3Commercial ❑ Trailer Curt ❑ Motel ❑ Other ❑ rW Numbs! of liv',ing unifis: !___-__ Number of bedrooms _ Number of baths .I__ Loi size _ o.`X.l - -_--•--•••••--------•-- ater Supply: Public system Community system C] -Pr ate.❑ Depth to Water Table Sd ft_ Character of soil to a depth of 3 feet: Sand a Gravel ❑ Sandy Loam❑ Clay Loam❑ Clay❑ Adobeld Hardpan❑ t 1 Previous Application Made: (If yes,date14S7.7..1.•.) No-El New Construction: Yes ❑ NoFHA/VA:Yes❑ No❑ '! TYPE OF INSTALLATION AND SPECIFICATIONI: r '(No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 r Distance from nearest well..-_...F.--...__Distance from foundation............ ......Materia L....:_--._.-____-_--_.__.---_--__-..--..... O"nk: �S'ize-------_------------ ."«..Li uid de th.---••-. _...Capacity --No. of compartments...................... . q P. r -•--•------ Disposal Field Distance from nearest well�Q�_.Distance from foundation.-1-4......-.Distant to nearest lot line_ r---_-- t Number of lines......�..�y__..- _ Length of each line___. 0...._.-._.,�__-__.Width,of trench..49.1_ _._-�_... ; Type of filfej,rna�teriaL__.,. ._ Q:" --_Depth of filter material--- -.`._____Total length.............. .......c -._-�_.. 9 Seepage Pit: Distanitc nearest wel�_0.KA,...Distance f om fo ndeticn_,�Q__._..._.Distance to nearest lot line_._............ 1 mit �r F Numberfof pita,,-.-L--_.=-. bo ._..Lining matenal�� --Size: Diameter_33_... - -- Qeptn.._.�- -_--•-----•---- - t �' Cesspool: ;"Distance from nearest,. well................'Distance from foundation._...._._-.-_.----Lining:material.___._............................... ❑ .:.Size:•Di meter.:... ............rte_. ----Depth_---•---•-----.- ---------- ........Liquid tCapacity---.-_.--------•-- --------gals. Privy: Distance-from nearest well__._..---------------------------------.........Distance from nearest building------------------------------------------ Distance ----____-------.-._-_.-•.__-------_----.Distance to nearest lot line......... .................................................----.....----...._.... .. ---------------.................... I Remodeling and/oi•repairing-+(desc-rife}-i_.............. i I , t' 1 1 ......--•••-----.-_-••--••.--- ......... t ! • i — 1 ................... -•.....--••--•-•------.....-•----.... ........................................................................... ----------- a.. '- `: I hereby cert" that I have prepared this application and that the workTwill.be`done in accordance with San Joaquin County ordinances, St I ws, anq rules and regulations of the San Joaquin Local Health District: Si nod .......................... y_ .+ -- �• wrier and/or,Contractor) ( . --•----------------- the c........................... . (Plot plan, showing•size of lot, location0,04nsystem irelati wells, buildings, etc.: can be pla a an reverse side). I FOR DEPARTMENT USE ONLY s APPLICATION ACCEPTED BY...--:_. I-•-••-•.................... DATE!._. _..r^.1/ �rl / _ ........... DATE" #........ --•-•............................•--••-• f ..........---••----- -- --- BUILDING PERMIT (_?SUED' ... .� ...� DATE- - - :._... REVIEW D --------------•--- •--------.... .. Alterations and/or,recotztmendations:..... --�--•=•"�=`�'�-- `--••- ----------------------------------------------------------------_-_------- - It fNi .........................-. ...........................•---...._.....__......••-----•---••. '" .— ... Date.......... 1 ' ..........-•-- FINAL INSPECTION BY:.--... ..... ... :..... .-- AN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Naselton Ave. 3 0 West Ook Street 124 sycamore Street 705 West 9th Street Stockton,California Lodi,California Manteca,California traey,California EG o nEv,sED a-ss 3M 3-•i3 r.P.ro.