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�i / - _._...../-----------------------7---- APPLICATION FC}RIWTATION PERMIT Permit No. .. _,1 (Complete in Duplicate) _ 1... . This Permit Expires 1 Year From Date Issued Date Issued ....� Application is hereby made to the San Jdaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance witli County Ordinance No. 549. JOB ADDRESS AND L TION _._.-s.2-Q ,� r ........................... .. ----------- ----- Owner's Name... ---- -•-•• -- .--- - • --•-••------------------------ -----•----------- Phone E AddressS -•------------------••--------------------------------........---------------....----=------••-- Contractor's Name.._- -•• ---•-•----_... •---••-------------------------------------------- Phone................................... J Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ j Number=of living nits: ---t... Number of bedrooms .J--- Number,of baths ....I-.. Lot size .&S----?�-.J._2_0........................... Water Supply)Public sy4stem JK SCommunity system ❑ Private ❑ Depth to Water Table E-.j_ ft. Character of ss ail to a depth of 3 feet: Sand ❑ Gravel ❑ Sand Loam ❑ Clay Loam E] Clay [3 Adobe 0 Hardpan C] I Previous Application Made: {lf yes,date--------------------) :No New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: s (No septic tank or:cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well �D ista�c�from o'u �ion� e� M I_� . . .. '. No. of compartments. 1� q -!-----�rCapacity..,`�o L. Disposal Field: Distance from nearest weli.��_Distance from foundation---IQ_._._�.-Disfance to nearest lot line.._,5�_... Number of lines.....r-------------------------i;Length-of-each line----"�T-O-.....___..-.Width of trench------- ¢......_. ._..:J ' jo0 Type of filter material. P = . .Depth of filter marferial_.. ........Total length....-....�a_ ----------- Seepage Pit: Distance to nearest well...................I-Distance from foundat of nom...�!� `Distance to nearest lot line........;I......-� ❑ Number of pits .........•-----------Lining materiel_!!- - ----- ---Size: Diameter....•----.-......._..Depth------------------•---• ......• Cesspool: Distance from nearest well-_----........Distance TWfrom foundation....................Lining material.. ..-----------_...._._�_ _.-.-.� ❑ Size: ;Diameter-------------------------------------!-Deth-------------------I ----•------------------------Liquid Capacity ii.IF aIs. G f Priv I i I Distance from nearest building �.. y:� Distance from nearest well------------------------------•-------------___-- __6 ❑ Distance to nearest lot line--------------- ------------------ r ----•••---••--------------•-------•--------------------- ------j- ........... _ 1 delin d/or repairing (desa :-- ..Remonei ----------------- •------•-._-- y#------- �+ ...... ........= ------------------------•------• -------------• { -----------------------------------------------------------------------•-•••--...........-••••--•-•-------•-•-------------------------------•-----------•-------•------------------------------------- herebycertify that=l have r'epared this application and thaf,the.work will be.done.in_accordance with Sen,Joaquin_County', ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. t ' (Signed).. -------------------- -----(Owner end/or Contractor) BYYC--- - ....... -••--• - _._ ........---------.....(Title)---------------------------------------------------------- (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-----/-- REVIEWEDBY----------------- I.•...----••----' -------------- DATE.-----•---•----------------------------------------- ----- -- --------------------------•--- ----- �-----------------------:- ....-- BUILDING PERMIT ISSUED-----------------------------------------------------------------..-.------------------------------- DATE-------------------••--=---------•---_---- _ Alterations and/or recommendations: -------------------------- ---- ----------- -----------------------_----••----- ------ •. . - ----- ---•-•- -------------------------------------- --- FINALINSPECTION BY:.I--------------------------------------------------------------------------- Date------------------------------------------ ---------------_---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street t 300 Wast Oak Street 144 Sycamore Street 405 West 9th S+r4aT l Stockton,California Lodi,California Manteca,California Tracy,California [ ES REVISED 0.591 2T5-61 ATLAS .�h