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9_,7 .. 2 i {Complete 1n Duplicate) This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described ; j. This application is made in com liance with County Ordinance No. 549. it JOB ADDRESS AND LOCATION . --.------------ r ----- � ° Owner's Name---- ---- -------- ----- Phone---------_--------------------- ----------•---------------------------------------------------------------Address 2.1,1014�14 ------------------------------------••------ Contractor's Name---------..0 ---- Phone----_--------------------------- _-4; Installation will serve: Residence ❑ Apartment House ❑ Commercial4 Trailer Court ❑ Motel ❑ Other ❑ Number of living units- ________ Number of bedrooms ________ Number of baths _°e1_-___ Lot size •___�'e�'.�-��__________________________ Water Supply: Public system ❑ Community system ❑ Private [9 Depth to Water Table/_17__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe P Hardpan ❑ Previous Application Made: Yes ❑ No q New Construction: Yes2] No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: {No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest welf____S -pistance from foundation_'- Z f i 7-1 a .. 3 No. of compartments_______ ________________Size S__ . O ------Liquid dear)------�----- ---------Capacity----�� ----- Disposal Field: Distance from nearest well_- -------- from foundation_______ Distance to nearest I t,lino___ _____..___ J ] Number of lines------ _- Length of each line_____n� ______ ________Width of trench__��'�_ Type of filter material,�C ______ __ _____Depth of filter material______- f----____Total length_____ ----------------------------- Seepage ,--_--•---_-__---_ _ Q Seepage Pit: Distance to nearest well------------------- ---Distance from foundation--------------------Distance to nearest lot line__-_______-_____ ❑ Number of pits------ ------Lining material-----------------------Size: Diameter------------------------Depth-------------------------- W Cesspool: Distance from nearest well-----------------Distance from foundation------------------- materia)__-_-_-__________________________ V ❑ Size: Diameter------------------------------ ---- -Depth----------------------------- ------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_____________________________ ------ -Distance from nearest building------,----_--------- - --- ❑ Distance to nearest lot line-------------------------------------------------------------- Remodeling and/or repairing fdescribe):---------------------------------------------------------- ------------------------------------------------------ ---------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- i ---------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------- •„# I hereby certify that I have prepared'fhis application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of f e San Joaquin Local Health District. (Signed) ,-- ------ "'q--------------------------------------- . .$Y: = caner and/or C40raclor,.;- �� - (Title} - - ....... (Plot plan, showin size of lot, lova ion 0f system'inrelation-to-wellsbuildings;=etc.,-.canbe-placed on reverse side).•,..:,_ f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE y aP REVIEWEDBY------------------------------------------------- ------------------------------------------------------------------- DATE----------------------------- -- UILDING PERMIT ISSUED-------------------------------------- ---�- --------------- DA•TE--------------------------- -�- ------�--- --------------- A terations and/or recommendations:------------------------------------- ----------------- ______-____- _-____-__------------- -----------_---------- ---- •------------•-------•------------------------------------------- ---•------ --------------- ----- -------------- FINAL INSPECTION BY:. � Date - ^� ��1 ..r - - -- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT # 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, Californiaz Trety, California ES-9-2M Revised 8-'59 F.P.Co.