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J132 APPLiCATION rORZANITATION-PERMIT (Complete-in Duplicate) r�pplication is hereby made to the San Joaquin Local Health f?istrict for a permit to construct and install the work herein described. r �fhis application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION---------------------------------------------------DL_ e-A—)-------- _T ' Owner's Name----------------- 14L_B4P-]—_-------- ----------- Phone-- a - vAddress------------------- =7 G D Contractor's Name--------------------------------------------•------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment Nouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: r1 Number of bedrooms ❑ Number of baths ❑ Lot size_______�_°z-. k �s ---------------------- a Water Supply: Public system ❑ Community system❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Aclobe;K Hardpan ❑4� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation---------------____.Material------------------------------------------------ . No. of compartments ___ a ____Size-----------------------._ .Li p ❑ p -- ------Caci p ty------------------- ----.. quid depth-, Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-------------------------------------- T-1 _______--____.____________-_-----.'❑ Size: Diameter-------------------------------------Depth-------_------------------------------------------- Privy: Distance from nearest well----------------------------_--------------------Distance from nearest building____________________________________- ❑ Distance to nearest lot line------------------------------------------------ Seepage ____________________ __________________________Seepage Pit. Distance to nearest well------Z0.0------ Distance from foundation----A;F---------Dist�n fe to nearest lot line___ ❑ Number of pits-------._----------Lining material-----------------------Size: Diameter___..-_ _!J_________.Depth______+rl__ _:_.:�_________ �isposal Field: Distance from nearest well-----_------------Distance from foundation---_----------------Distance to nearest lot line_________-__.--__ ❑ Number of ---------------------Length of each line------------------------------Wiclih of french----------------------__-_---__---- Type of filter material_______________________ Depth of filter material----------------------- Remodeling _________--------- -_Remodeling and/or repairing (describe):--------- - t��-trl-------- --------------- ------ ---------`---------------- _ ----------> U ---------- -- --------------------•-- ------------------------------------------------------------------------------------------------- -------------------------------------------- I hereby certify that I have'prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St to laws, and r les and regulations of the San Joaquin Local Health District. (Sign � -----------------------------------`- ----------------- ---------------------------------------------(Owner and/or Contractor jBy:------------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- - -------------- t",r'^------------------------------------------------- DATE.------ n Q-------------------------- REVIEWED BY------. --- z ----- ------ ------------------------------------------------------------------- DATE S`------------------------ BUILDING ---------BUILDING PERMIT ISSUED-------------------------------------------------------------------------------------------------- DATE------------------------------- ----------------------------- Alterations and/or recommendations________________ k ------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------•- ---------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------- �ERMIT No.____ �--------------- ISSUED--jf'.21�"__5'0--------=-------(Date) FINAL INSPECTION BY:----� -- ---- ------- Date------------------ _40-------- JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639 t fes.