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\~ ' APPLICATION FOR ANITA710N PERMIT S Permit Nd, 7,5 ....---.. - ,. , .z (Compllete in Duplicate) 4 Date Issued Applica+ion 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. JOB ADDRESS AND LOCATION:----- xAlt'111a---------------------- --------•------------------------------ -------------------------------- r i r hHO ---ber't Co 1� - -- - ---------- Owner'sone y--A.,---= -•--- Name_ -�----------��-_---------. _---- _�,. .. . n -- ....:.._ -- --------------•----------------.....-------•---• Address - ----------------------------------------------------•------------ = " ------------------;...---------------- k ,. ,.• 3 .1269 Contractor's Name-------------De�_t&--------- -------- ---- ------------------------10--- = -------------- Phone-.--------------------------------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 � X -------------------- ----------- Number of living units: �-_____'Number of bedrooms ---__2._ Number of baths _.__l_ Lot"size ___ _ Water Supply: Public{"system'] "Community system ❑ .Private ❑ Depth to Water Table 4Q-- ft. Character of soil to a depth of 3 feet: Sand ❑ -Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe[3 Hardpan ❑ 1- Previous Application Made: Yes 0 No [?j New Construction: Yes ® No ❑ n TYPE OF INSTALLATION AND S.PEC�IFICATIONS. ( NN ( p .p P sewer is available within 200 feet.) Septic Tank: Distance from nearest well--------____------Distance from foundation-----------__._.___'.Material____________.__.--.__-.._____________..____._. No septic tank or cess ool` ermine i public eXEbting p - --- Size--------------- -----------•---Liquid depth-_-- -------------------Capacity------------------- p No. of com artments________________.__ Disposal Field: Distabncce from iirtie"nearest well..------------- Distance from foundation-------------:�.-...Distance to nearest lot line-____________- exUating " _.------_----------- i Length of each line----------- ` -.Width of trench_ ------ i >✓10 ; ter -----Total length-------------------------------------•---- SeepagePit: Distance to nearest well'__________________Distan am fo tion_ -____`_..' Type or filter r�atenaL___.__-____-„_:______-'_Depth of filter materia_...______ ` -- 01 '_.'Distance.to neare o . ■ x Number of pits.------ 1. ---Lining materi I-----_4r-�C�.- e: Diameter__.._.__ 1_--------Dept --- --3T -- - - ---- I Cesspool: YN Distance from nearest:well_________________Distance rin foundation.,'.-_'.__---.I_.__lining material__..________--.-___.___._-_________- I _ ------- ❑ Sizei Diameter Depth----------------- ----_---------- =�------=-- ------- Liquid Capaci+Y gals. Privy: Distance from.nearest well._.__„_----------------- ----_----- ----Distance from nearest building,!__.______..--------______________-----. i ❑ — `Distance to nearest lot line._ '"____________ __ `- --------------------_-- ------------------------------------------------------------------- addin see a �t---t°---exstfng sic system--------- Remodeling and/or repairing (describe):----------------------------- ------------per.••.p __ _ k -------'-------- ----------------------------- ---------------------------,-- ..------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. 1 o ---------------------------------------------------------------(Owner and/or Contractor) t_ (Signed) --------------- P*W* size of lot location ------p'.W ----- - -- ---•-- ---•------- ------------------------(Title)_Gen.Mgr.------------•---------------------- (Piot plan,'showi g of system in relation to wells,:buildings, etc., can be placed on reverse side). l E FOR DEPARTMENT USE ONLY ------------ APPLICATION ACCEPTED BY....... ... .........__--_ �------------------------------ --._ DATE / ."1----------------------_ REVIEWED BY-----1----------------- ----- - ta - DATE ..------------------------- BUILDINGPERMIT ISSUED--------- - -- -------------------------------------------------------------------- DATE-;=-----:f----- --7 ----------------------------------- Alterations and/or recommendafi -- --- -----•-------------•------ -•-------------------------------•..._. --------------- --------------------------------------------------------------------------------------- ------------------------------- ------ --- •----------------------•--•------ --------- - --.................................--------- --. --------------- -----'------ -----------------------•-------------•---------.---------------------- •----------------- •----- ---------------------- FINAL INSPECTION BY:_____.: -.-- _. Date---------------------- -- 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, California Tracy, California ES-9-2M 145446 PTWOQO 12.54