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FOR 01`F19E U : }} APPLICATION FOR. &,�WITATION PERMIT Permit No. ------------ ---- ------- ------------------------ (Complete in Duplicate) f This Permit Expires 1 Year From Date Issued Date issued /� ...ems. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describe This application is made in compliance with CourLty Ord'nancce%N]o. 549 2xZ XJ013 ADDRESS D LOCATION_________________ Owner's Nam • -••-----•--------•-•--• Phone...............----------------•--- Address. V/ -; ---------•----•--------•------•---•............... Contractors Name---------- .... ......... tY� ` �,l��- ---�-��---d-J----•----••------•---••--•........................................... Phone -- -�•�- - Installation will serve: Residence 0--"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [3 Number of living units: .___ Number of bedrooms __. Number of baths __/-• Lot size ---------,��_�_---------ter_ Water Supply: Public system E] Community system [IPrivate K Depth To Water TablerQlO ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [Adobe❑ Hardpan Previous Application Made: (If yes,dote--------------------) No ❑ New Construction: Yes ❑ No Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) nk: Distance from nearest well_________________Distance from foundation--------------------Material-__.._---___-_.___.'----------- .----------- .___.. No. of compartments----- --------------------Size................................Liquid depth--------- ------ ---------Capacioty'line -•-----------------•-- �posal Id: Distance from nearest well-----------------Distance from foundation....................Distance to nearest ___________._---_ J ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material------------------- ----Depth of filter material------._-..------- Total length------------------------------------- p / pp Seepage Distance to neareir ell_5]. _ -__....Distance from foundation... . .....__.Distance to nearest lotNumber of pits____ ___________Lining material _ ___ __ ___.__.Size: Diameter____ _ _________Depth_____ _ "----. fa Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_________.._____________________.___ E] Size: Diameter--------------------------------------Depth_----------------- -•-•------ -------------------.-Liquid Capacity--------- ---------------...gals. Privy: Distance from nearest well-______________________________.____-- -------Distance from nearest building_____________________________________-___. 0 Distance to nearest lot line---------/----------------Q---•------ -------------- - ---------------------------•----•---------------•---•----------------•-•--------------------- Remodeling and/or repairing (describe):------ -, ^-___+ Lam'G� " _ __ ____ L-._._.__ ----------------------------------------------------------------. ------------------------------ ---------------- --- -------•------------ -------------------------------------------------------------- ---------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- ----------------------------------------------------............-----•--------•-----------------..._.....----------------------------------------------- hereby y that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinance , t aws, an rules and r ulations of the San Joaquin Local Health District. (Signed)----- - ....-- -- --- nor and/or Contractor) ------ - -------- --- ------ - 11 By:............................................... ----- ----- -- -- -------- --(Title)----- -- ---t (Plot plan, showing size of lot, location o system in relation t Is, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ------------------------- ------------- 1 DATE_. REVIEWEDBY------------------------ ------------ DATE----------------------..---•-------------------------------- BUILDING PERMIT ISSUED-----------------------------------------------------,---------------------- ---------------_- DAME----------- ••----- T-y- --- -- - -- -- - �----------- dAFterations and ar e _-_ It 61 Z-V ---------------------------------------------------•- ---- f -- / V FINAL INSPECTION BY:--....Ae�--- ` tf ----------- Date..--- l .- ' SAN JOAQUIN LOCAL HEALTH DISTRICT { I 130 South American Street 300 West Oak Sereet 134 Sycamen Street 205 West 9th Sheet Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED 8.59 2M 5-62 ATLAS I