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l APPLICATION FOR ANITATION PERMIT � Permit No. ___"�.J------------- (Complete in Duplicate) J /( o Date Issued _______!-__._. .._.. Applica4ion 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--- ------�'-- --- ---------•-•-----------qt�l ------------------------•=--------------------------------- Owner's Nam ----- �. --,,_ ll (3`Y ----A -------------------- -------------------------------- ----- -- Phone---- U� Address--- �4t!.. ---------------------------------------•-----------------------------•--•-------------------------------•----------•------------------------------- :a Contractor's Name------ ---•------------------- --•------------------------------------------------••---------------------------------- Phone-A0.1---l. #S-a•- Installation will serve: Residence VApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I____ umber of bedrooms ___'". Number of baths ---1... Lot size ___1�___._ __"'l�d-~4__R_____________________ Water Supply: Public system`[ mmunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No VNew Construction: Yes SKNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well_________________Distance from foundation--------------------Material------------------.------------------------.__-_. �.. No. of compartments----- -----------------..Size--------------------------------Liquid depth--------------------------Capacity----------------------- m ell...__-_- Distance'frofoundation____________________Distance to nearest lot line________-__. Disposal 1 iel Distance from nearest w ..... Number of lines--------------------------=-------Length of each line--------------------------.._.Width of trench----------------------------------- Type of filter material____._ __--------------_Depth of filter material---_------------__.__.Total length__-.____--- -------------------___-__ Seepage if: Distance to nearest well_ _O`___-_._._Distance from f undation____-�.Q.-__----Dist�nce to nearest lot lin r rZ ""€----------------- �. Number of pits---------i__=,._,}'..Lining material.�'+� --.Size: Diameter.__-_.�-------------Depth__.__ S ____.___._______. � I ' Cesspool: Distance from nearest"welly____=__._.._ Distance from foundation-_-----------------Lining material------------------------------------ EJ ______--- ----____.___-_______❑ Size: Diameter------------------------ M1 Depth`-----------------;•----------------------------T----Liquid Capacity----------------------------gals, Privy: Distance from nearest well-------------...--------------------------I.......Distance from nearest building-..__..__--__-.______________________.___. ❑ Distance to nearest lot line________________________ -- --------- --------------------------- ----------------------- ------ Remodeling and/or repairigg (,,describe)_ _-------________________ t ---------------- L! ----- ------------- , ----------- ----- --------•----------------------------------------- --------------------•-------- -------------- I 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, (Signed)______ � Z _______(Owner and/or Contractor) By:-------- ------- ----- ------------(Title)--YY1 ' _(Plot plan, showing sizlot, locatio of system in relation to wells, buildings, etc., can be placed o reverse.side). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ------- - s = DATE--------------- REVIEWED BY----=----------------------------- -- -- ---- --------- - --------------".-.`--- -------------------------------- DATE---- ------------------------------------------------- BUILDING ----- �----------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------- ------------------ DATE-------------------••--------------------------------------- Alterationsand/or recommendations--- --------------------- = --------------------.....------------------------------------------{---------------------•---•----------------------------- --- ---------- °--------- -------------------- ----- ----------------------------- ---------------------------------------------------•---- ----------- ------------------- ------------------------------------------- ------------------- ---------------------------==-------•--------------- ---------------------------------------------------/1.---------- ----------------------------- ------------------------------------------------------------- ----------------------------------------------- -•--------------- -----------------------------• ------------------------------------------------------- F1NAL INSPECTION BY:.._'-- -------- ---------------------- - Date--- ...5-h-.0 � 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 14S446 ATWOOD 1254