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F R OFF CE U,SE: ------ °�'f�f/ -------------- I -- ________________ ______��_..__.___= -�______ APPLICATION �OR✓$ANIYATION PERMIT Permit No. ...1_�L..1�X(.3(Complete in Duplicate) d'` ----------- This Permit Expires 1 Year From Date Issued Date Issue ..... -,. 'l. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. 3 JOB ADDRESS LAND LOCATION_.- 7, ec" -----•------------------------------------ -----------------------------•------••-----••-----....--------•---------------•--------------------------- Owner's Nam ------------•------------- ------ Phone--------------------------------•--- Address---------- ��.5' Contractor's Name------ - ------------- --T-.%--•--------------------------------------------------------------------------------...._.------ Phone................................... Installation will serve: Residence eApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -__J. Number of bedrooms ._Number of bath ? ire ✓t� Water Supply: Public system Community system ❑ Private ❑ Depth r 41 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ ` - .. a t Y Previous Application Made: (If yes,date------------------._) No New Construction: Yes eNo ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest well_________________Distance from foundation____..._____-______-Material....___________________-_----_----_____________ No. of compartments--------------------------Size-------------------- ..........Liquid depth--------------------------Capacity----....................... Dispos Field: Distance from nearest well '______Distance from foundation.40------------Distance to nearest lot line-_11.1__.-........ Number of lines_____-��__. -- Length of each line----�lI__`_____----------Width of trench-_ �! Type of filter material...__.. __.Depth of filter material_-_./$_._5---------Total length______TO-!---------------------------- p cam` �' pistanceom foundation.- :- p See a Pit. Distance to nearest well ________________ .,�+1?______..--_.Dist ante to nearest lot lines__.._..._._ 'V Number of pits ____Lining material__ k6-C. Diameter-33 Depth_.___`�,S_._-_f_ _____________ Cesspool: _ Distance from nearest well-________________Distance from foundation.._________________.Lining material____._..______,____.___________-_-_-_ [❑ Size: Diameter--------------------------------------Depth--------------------------------------------------•-Liquid Capacity-.--------------------------gals. r_ Privy: Distance from nearest well________________________________________________Distance from nearest building____-____________________________________. ❑ Distance to nearest lot line------------------------------------------------------------------ --- Remodelingand/or repairing (describe):-------------------------------------- ------------------------------------------------------------------------•-------------•-•-----------•------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----•--•-------•-•---------------------•------•-•------------••-------------------------••-----•-----------•--------------------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 t San J aquin Local Health District. (Signed)-------------------------------------------------- ------------- ------- ----------- ---------------------------------------------------•-------------------(Owner and/or Contractor) By:........................................--------- --- - -- - ----- --------------------------------------------------------(Title)------------------------------------------------ ---- ----- - - , (Plot plan, showing size of lot, location of s in relati to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.... .. _>------ DATE REVIEWEDBY --------------- ------------------------------------------- DATE---- --------------•----------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------- ----- ---------------------------._- DATE.-----------••-----------------•----------------------------- Alterationsnd/o/r recommendations:--------.___ i ::_r �_�_ ./_F .. rte_ =-• -4-:�- --Cl. _.{ ---- -z="a• c-------• f..._.--'I�..�.- 7-�---.ct�., '`r f --- G' l ______________________________________________________________________________..__.___________________.____________-__--_-_______________.________._......_______________.____.._________._-______.___.._..........____..______ FINAL INSPECTION BY:.......... ------------------ Date-------------------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California + F5 9 REVISFO a-59 2M 5.62 ATLAS