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FICE USE. <br /> - 171 PERM <br /> �' ----------------------------- (Complete in Duplicate) �J G <br /> ` .----- This Permit Expires 1 Year From Date Issued Date Issued ._--_--I- -_ <br /> Application is hereby made to the San.Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION...-- l = "t 1 - �E,C?. Q ----------------------------------------- <br /> Owner's Name------- ---- --------- ---------------------Phone---------------- <br /> Address--------------•-------- - -- -------------1 rX- -- ---------•-------------------•--------------------------------- ......--•------- <br /> Contractor's Name p - ------------ --------------- Phone <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ T.railer Court ❑ Motel ❑ Other o 72Ae"—�--- <br /> Number of living units: . _ _- Number of bedrooms __'Number of baths ___--f_ .Lot size _-- �, --, Cal. --------------------- <br /> Water Supply: Publiclsystem ❑ Community system ❑ Private E4 Depth to Water Table -------- ft. <br /> Character of soil to a depth of 3 fe 6t : Sand ❑ Gravel [I Sandy Loam El Clay Loam Clay E] Adobe ❑ Hardpan F]Previous Application Made: (If yes,date------ No ❑ New Construction: Yes No ❑ FHA/VA: Yes ❑ No>K a <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No Septic tank or cesspool permitted if public sewer is available within 200 feet.) a- <br /> Septic <br /> Tank: Distance from nearest well--_-��•___Distance from foundation--- --- Material-_--- - <br /> f - -�--Z•�� <br /> No, of compartments............ ..�.---- Size-------------------------�---Liquid depth----------�- _--_-_-CaPacity----- <br /> C? <br /> , <br /> Disposal Field: Distance from nearest well------5 ._Distance from foundation------/�-'�-.Distance to nearest lot line------- <br /> Number of lines-----Y----------/----------------Length of each line-----.-------- '0--------Width of trench-----------=-I/-, 1(----------- <br /> - <br /> Type of filter material t.�`?--+Depth of filter material--------te-1t-----Total length---..--.-__-_-.:-..- --------_-- <br /> Seepagp Pit: Distance to nearest,well-__-__--_ ___Distance from foundation------ 4 _ .Distance to nearest lot line----- r- <br /> DK-_ Number of pits.......'---1--------Lining material--- —Size. Diameter._.---4�'r.-__-.Depth_-._-._-.-_ .- <br /> Cesspool: Distance from nearest well----------------_Distance from foundation_- -Lining material---------- --------------_--._--. <br /> Size: Diameter ---------- Depth <br /> ❑ r'' -------Liquid Capacity---------------------------gals. <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest,building------_--------_-----_------.----..--.---- -► <br /> ❑ Distance to neare' lot-line------------------------------------------------------------------------------------------------------------------------------- ---- ----- r <br /> Remodeling and/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------•- 9 > <br /> ------------------------------------------------------------- ------------•-••------------ -----------------=---------------------------------------------------------------------------------------------------------------- <br /> I } 111 <br /> i r <br /> ------------------------. -----------------------------.-------------------------•---:-:-------------------------------------------------------------------- r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulatioijs of the San_ Joaquin Local Health District. w <br /> (Signed)------ =: - ------- :- ------------------------------------------------(Owner and/or Contractor) <br /> --------------- - -------------------------- --------------------------- Title - ---- <br /> By--------------- _-------_- •-• ( ) <br /> (Plot plan, showing size.of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY-------- ----------- �J�l DATE--------- - _---;--------- <br /> - <br /> REVIEWED BY------ ------------------------------ ----- - ----- --------------- -- DATE t <br /> i` BUILDING PERMIT ISSUED--------------- -- ------------------------------------- <br /> ----- --------------------------------------- DATE---------------------------------------- ----------------- -- <br /> Alterations and/ r recommendations: - <br /> -----• -----•-----•------------- - - - -t <br /> -•-- -_...----•-1-----` - <br /> -•- --------------- <br /> r ------------- ---•------- --- <br /> --------=------------- <br /> ------------------------ <br /> -------------------------------------------- ------ <br /> -------------------------- <br /> -------------- <br /> FINAL INSPECTION BY--------- ------ -------------------------------------------------- Date-------------------- -------- -------------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.Hazelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street <br /> Stockton,California Lodi,California Manteca,California Tracy,California <br /> Es 9 REVISED 8-59 3M 3--53 F.rl.CD. <br /> f � , <br />� 1 <br />