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Permit No. APPLICATION FOR IITATION PERMIT --�-_-. y,R L: {Complete in Duplicate) T. Date issued Applicatiorn is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. 1_ JOB ADDRESS AND L CATI N_ - f ` ------- -------- ----- - - Owner`s Name - u v*`r Address Contractor's Name--_-j_ ° b2 '-v-_-------I_ ------------- Pon z - . Installation will serve: ` Residence � partment douse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Others❑ iNumber of livi� units: ---f_-- Number of bedroom' i Water. g �--- Number of baths --- 'Lo+ size _--_ Supply: Public system-El, Community system E] Private ❑ Depth to7Water TableT. ft,.— 1 Character of soil to a depth.of 3 feet: Sand Q Gravel ❑. ,Sandy Loam ❑ Clays Loam ❑ Clay ❑ Adobe Hardpan 0 Previous Application Made: Yes ❑ No ❑ �fNew Construct ion: Yes',0 No [❑ =FHA#/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: {No septic tank ar`cesspool permitted if public sewer is available ithin 200 feet.) Sept'c ank: Di'stane.from nearest"well"�"""° � Distance from foundation-:.-:--v,- --------Material-----------------------------------------_.-__-. ' No. of compartments -- ------- ---Size--------------- 1----------Liquid.depth----------------------- 4 Capacity----------------------- is ------------------- • I , � � -- ispose geld: Distance from.nearest w - e_ istgance from founda#ion-_.-}--- . _----.Distance #o Barest lot line----------------- Number of lines ti"-' .---- ---- .---- Length of each line------------------------------Width of trench.----------------------- f �• Type of filter material----}:____ -----------' a yp j --Depth of filter mS aterial----=----------------Total length_�----------.----.---------_ M° r . Seepage Pat: Distance to nearest:we I- _--'_Distance from fo dation_=_ls;7___-__•--_-.Distan a to nearest lot L r 1 Number of pits-- _ -'__i---Lining materiaT Il------ f ----Size: Diaeter------sp -----Dpth---`jCd--------------------- Cesspool: Distance fromj.nearest wel�'}` 1-Distancefrom found T-1 - _-_ Lining materil_------k -------------------------- Sizis Diameter Cli t ,---------'-Depth---=----------=---=------------ =��-��---„- Liquid Capacity---------------------------gals . Privy:�. Distance from nearest:well___.-------------------_ -____-._--_-__- _.'Distance frorn i nearest building- _-_- ❑ Dis+ance-+o nearest lot-line---- ------------=- . ' j ----------------------------------------' ' E Remodeling and 'fir^ ' r /or repairing (doscribe):- ' -- i - ------------------ ------------------------- ------- I -� ----------------------- -----------------------------------------------------r I hereby certify that I have prepared4his application and +hat the work will be done in accordance w,,ith`5an Joaquin County ordinances.--State laws,:andirules and-regulations'of Me San Joaquin Local Health Dis+ricf. 1 (Signed)- ------ } -- ----------- ------------------------- ` (Owner and/or Contractor) i ------Title By: �- - c - (Piot plan, s owing siof lot, location of system in relation to wells, buildings, etc., can be placed on reverse i , 5 FOR DEPARTMENT USE ONLY. APPLICATION ACCEPTED BY----=------- ----------- ----------- -------- ------------------------•-----------------------:----- DATE--------------. , � --------------------•------------ A�',IEWED BY--.-----•---- -------------------------------- - ------ ------=-------------------------------------------------------- DATE------------*- BUILDIN PERMIT ISSUED ------------- - - -- ---------------- ---- ----- DATE--------- Alterations and/or recommendations:--- ----- ” - --------I-------------------------------------•----------------------•-------- i "' - = f'1 s ., c� - .ter. ----------------------------- _...---- -------------------------------------------------------------- --------------- , - _ ------�--av2 � r,� -----33 ------ ---------------- ---- - ------ FINAL--INSPECTION. BY:- f _ - Date-- '- --- ---------`�'------ -------- ------------ � M- SAN JOAQUIN LOCAL HEALTH DISTRICT 'r 1 130 South American Street 300 West Oak Street ` 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California —Manteca, California Tracy, California E5-9-2M , Rev;secs 1•57 F.P.CO. E