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APPLICATION FOR —.,MTATION PERMIT Permit No. ..--... (Complete in Duplicate) Date Issued ApplicaCion is hereby.made to the San Joaquin Local Health District for a permit to construct and install the work herein described. C--his application is made in compliance with County Ordinance No. 549., -- � ------------------------ F" f .s - •�► ----- _-- - JOB A DRESS LOCATI N �l�2t_ _ I � Owner's Name— _ tl«_ _A�__ -_L_A4 ---N) , l =� ---------- - - ------ Phone_JkC---q-4-711- ...... Addres ___ __.-td— dx te r -_ Phone - --^ `— -------`--- Contractor's Name -�--^---- Installa+ion will serve: Residence ❑ Apartment House ❑ Commercial frailer Court ❑ Motel Other ❑ Number of living units. __..-___ Number of bedrooms -------- Number of baths ________ Lot size Water Supply: Public system ❑ Community system ❑ Private g, Depth to Water Table __ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan [I4 Previous Application Made: Yes El No New Construction: Yes ["No ❑ ` ....., TYPE OF INSTALLATION.,AND�SPECIFICATIONS:._ i _ - _ y- - (No septic tank or cesspool permitted if public sewer is available within 200 feet. ' A Septic nk: Distance from nearest well__ �._.-__.Dista `e from f�9undation--l_1�.--------- -_Capacity 2 Size_ a- -_4�A/!__Liquid depth--+3----- ------ ------- MI, ----- (� No. of compartments__.- ---------- I g _Q.--Distance to nearest line___ t Disposal Field: Distance from nearest well -_Distance from foundation-- Number of lines---------I-------------- ---------Length of each line------------- ----------Width of trench_ -- Type of filter material__------_------Depth of filter material---- - -......-f-----Total length----- ----•-----------•------•-- . +� ` __.Distance to nearest lot linf__-,E Seepage Pit: Distance to nearest well__RPZ__ '___--Distance from foundation_.It - ----Linin material_— --------Size: Diaer__.-.��---------- --- -------- L Number of pits_-_` _-___--- g -Cesspool: Distance from nearest wO----.-_-____-___Distance from foundation.....:............:.Lining material__-_._____.___.-._-.___-_---------__ f -Depth---------------------------------------------------Liquid Capacity------------------------- El ------------------------ gals. ❑ Size: Diameter-------------------------------- -- --Distance from nearest buildin ------------------------------------------ Privy: Privy: Distance from nearest well------------- ----------- ------- 9 •------- ---- . ❑ Distance to nearest lot line----------------- -- ----------------------- ------------- _ ' =----- ---- --- ------- -- - --- � -----�, Remodeling and r re airin (descri e):_ _ -- -- - - �S - -------- - '1t _ _ ---------------------------------------------------------- •----------------------- P�ere certif that I have re a d this a lic r - --- y P P pp atien 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. - ...� and/or Contractor) (Signed) - -'•- - ------------------------------------------ _ �.. -r.,.. ..».. ...-. _ ---�— - - ------ (Title) -------------------------------- By: ----- ot location of system in relation to wells, buildings, etc., can be placed on rever§i; side). [Plot plan, showing siz�f I Y ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ - DATA ---------------- --------------------------------- ------------------------------------ ..� REVIEWED BY----- ------------------------��..... DATE - BI�ILDENG PERMIT kSSIJED------------==�-=�------------------------------------- ------------------------------------------- DATE.- Alterations and/or recommendations--- -------------------------------- -----------------_--- --------------------------------------- - --------••--------------------•----------- -. ----------------------------------- --------------------------------------- ----- /�FINAL INSPECTION BY:---------- -------- Date 4 �_�._'�-.__(------------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street E30 South American Street Tracy, California Stockton, California Lodi, California Manteca, California Y 'h E.1 145446 ATWOOD -� ,