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1 APPLICATION FOR —ANTION PERMIT ITA7 Permit No. - --••�f--------- ---- d (Complete in Duplicate) ! S Date Issued ______---9/----- ' 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. JOB ADDRESS AND OCATION___'Z _ �. ----- ----- -------------- Owner's Name--- - ------ -- --- ----------- ------------------------------------------- PhoneU / r Address_.._", - ----------- 4Z 7 r Contractor's Name------------- --- ---- ---- ---------= P one.-- -- - �---- --- - i Installation will serve: Residence Apartm nt House [❑ Commercial ❑ Trailer ourt ❑ Motel Other ❑ Number of living units: __. --- Number of bedrooms __2_ Number of baths __/___ Lot size ------------------------- Water Supply: Public-system Community system ❑ Private ❑ Depth to Water TaHe�-_�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes [] NoNew Construction: Ye�< No ❑ FHA/VA:Yes ❑ Ng ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) eptic ank: Distance from nearest well"________________Distance from foundation--------------------Material______.______._._______-____________.___________- No. of compartments-- ---- ------------------Size--------------------------------Liquid depth---------------- --------Capacity------------- Dispos field: Distance from nearest well---0A __Distance from foundation-----1D-----------Distance to nearest lot.line____ __________ Number of lines-------------_f_.________ _ g Width of trench.___ Length of each line i5 �; -------------------- O Type of filter material.____. ....----Depth of filter material__ _!_g_________Total length-------19 ____________________________ �. � / r Seepa a Pit: Distance to nearest ll____Distance from f dation_,�11._..tC-__..Distance to nearest lot Number of pits----/--------------Lining materia Size: Diameter_„5,Y---.�--------Depth-- .-2w --,-------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------____________________________. ❑ Size: Diameter--------------------------------------Depth--------------------- ------ ----------------------Liquid Capacity-------------------------:--gals. Privy: Distance from nearest well__________________________________----------.._Distance from nearest b0clin _______________- g ❑ Distance to nearest lot line------------------------------------------------ ---------------------- -------------- ---------------------------------------------------- Remodeling and repairing (describe]:_ _____ _ -.- --- --_-- -- ---------------------------------------- --------------------—--------------------------------°--•"•----------------------------------------------------------------- ------------------------------------------------------- -------- I -------- I hereb certify that I have prepared this applicaf' and that the work will be done in accordance with San Joaquin County ordinance ate la and rul s regulati sof Sa Joaquin Local Health District. (Signed) ____ - (Own or Contractor) BY: -- ----"-----------------------------------------------------(Title -- ------ -------------- (Plot plan, s w' o on o sys em in relation to wells, buildings, efc., can be placed on re erse e). FOR DEPARTMENT USE ONLY IAPPLICATION ACCEPTED BY------------------- ---- -- -------- --------- ------- ---- ----------------------------------- DATE--------- r ----------------------------------- REVIEWED BY----------------------------------------------- - ---- - ------------------- ------------------------------------------ DATE---------f ------------------------------------ BUILDINGPERMIT ISSUED--------_--------------- - ------"----------------------------------------- DATE Alterationsand/or recommendations:------"- -------------------------------------- ----------------------------------------------•--------------------------------------------------------------- i -----"------------- ------------------ - -------------------------------------------••------------------------------•------- ------ ----------------------------------------------------------------------------------------------------------------------------------------------------------- ---------- ---------------------------------------------------- ----------------------------------------------------------------------- ------ -------------- -------------------------------------------------------- --------- ---------------------------------------------------- 19 6 FINALINSPECTION 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 Revised 1-57 F.P.CQ-