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OR OFFIC, '- . --------- ----- APPLICATION FOR ANI7ATION PERMIT Permit No. ._�. �.5_._7._?- Cf-- �'�- ----- -------�>/-`�� - ---- � . . (Camplete,in. Duplicate) --.--- This Permit Expires 1 Year From Date Issued bate issued Application is-hereby made to the San Joaquin LocalHealthDistrict for a permit to construct.and install the work herein described. This application is made in compliance with County Ordinance No. S49. '//� Z JOB ADDRESS AND LOCATION_. - • ---•-- ---------------------------------------------------------------------------- �� —� Owner's Name__. ----- ---------- Phone�C'-----��----- i Address----` = Contractor's Name -----•- --------------------------------------------------------- ------ -------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House [] Commercial ❑ Trailer Court ❑ Motel E❑ Other ❑ Number of living units: /__._ Number of bedrooms-a-..7__ Number of baths _7 _ Lot size __,7�`:� __- - --------.-___.___._ Water Supply: Public system .El Community system ❑ Private Depth to Water Table_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑- Sandy Loam E❑ Clay Loam ❑ Clay ❑ AdobeEl'-fHardpan ❑ Previous Application Made: (If yes,date.__-4",_.,___..._I No �' New Construction; Yes (g/No E] FHA/VA: Yes E] Previous TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool perrMffed if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_; __-_i___f'___Distance from foundationa __.__f t'_____-Materi L_P '�" L/ No. of compartments_:____-_—s____._____ ._Size.( ___'�.._Liquid depth------- Capacity,(-�Z."` r�' Disposal Field: Distance from nearest well __ +!.__5 /_Distance from foundation l_n ______. _7Distance to nearest lot line_:44--�/____ Number of lines___'_€------ _ Length of each line__-? " Width of trench_.::__��-�. ;. Type of-filter material___-tS_�_?7. __Depth of filter material___/�--`____.Total length___ } Seepage Pit: ; Dstance to nearest well----�_G'7-----Distance from foundation____/C Distance to nearest lot line` /____.._ Number of pits--------7?r=------Lining material-__/ �° -Size: Diameter__.__7_= .Depth---- - 17r';2-(_ ,oA Cesspool: Distance from nearest well_______________Distance from foundation____________________Lining maferia)_----------------------------------- 00 ti ❑ Size: Diameter------------------ i---- Depth--------------------------------------- -----------Liquid Capacity--. ------------------------gals. r Privy: Distance from nearest well--------------------------------------.-____.._._Distance from nearest-building_______.________________-_:___. ❑ Distance to nearest lot line----- -------------------------------------•---------------------- - Remodeling and/or repairing (describe):------------------------------- ------------- -------------------------•---------------------------- i y.. 1 -----------------------------.--------.-------------------------------------------------------------- J ; !� -----------------------------------------------------------_---------------__________------_-----------_-----------------------------------------------------------------------------------------_-------------- ____--__... ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State la s, andrules and regulons of the San Joaquin Local Health District. { (signed)- -------------- ------------------------- ------------- -----------------------------(Owner and/or Contractor] By:---------------------------------------------------------------------- -- ------------------------------------------(Title)------------------------r (Plot plan, showing size of.lot, location of system in relation,to.wells,,buildings, etc., can be.placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ ' ------ .- ------- ----------------------------------- DATI=------._�1��/ REVIEWEDBY'----------- ---------------------------- ------------- ------------------------------------------------,----------------.. DATE BUILDING PERMIT ISSUED-------------------------------------- -----------------•-----•--------------- ----------------- DATE -- Alterations and/or recommendations:._..___. _ �` f! -: -•: -_ —_�-------_ ------- ------------ _____ [ c �� v f -. ' -[J _ rJJ/� �..[�-r •--�- ------------ YiJ�.1. �/•�'fF_""__ '.~. ._~�Yr�'_ ------ __I- � -- ---- � ,_._ l ;r -72 ; FINAL INSPECTION BY:.��. . f. ----x- ----..._ Date-__ _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Haseltort Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California E9 9 REVkSED 8-59 3M 3-'63 F.p.p q. �