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OR OFFICE USE: 3 ------------------------ - ----- `�_ APPLICATION FOR $AK ITATION PERMIT Permit No. s: ........... ---- (Complete in Nplicate) --- ------------------------------------------------.--. I This Permit Expires 1 Year From Date Issued Date Issued 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 LOCATION__- poQ 19 ,x----- ------- Owner's Name--- - ------------•---•-------------•-- ------------------- ------------------------------------------- Phone--- lb:l------------ Address-----•------- "`---------------------- -------- Contractor's Name---- - -------------------------------------------------------------------------- ----•------ Phone................................... Installation will serve: Residence D Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___A___ Number of bedrooms--- Number of baths ._�____ Lot size ----------1'a_--�_--------_------------------ Water Supply: Public system ❑ Community system ❑ Private W Depth to Water Table hO._ ft. R4%* 1y% Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe j< Hardpan ❑ Previous Application Made: (If yes,date--------------------) No )< New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No.56 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---la0�-.Distance from foundation-----Q' Material--- ------------------------- No. of compartments-----an_.___!____Size_�x_`-�..K_A_�-....---Liquid depth____-_____--___________-Capacity-____l _e Disposal ,ie Distance from nearest well__0_aa-_-_-._Distance from foundation__3 _..__...Distance to nearest lot line----\P.�..._. Number of lines-------- __-Len Length of each line_______ �� t------------ 9 f+Z-------------------Width of trench------9------•----------------.. Type of filter material_ 4'__-iar1'\___Depth of filter material----1t--________.__Total length--------2-0'_:_-4________________;. Seepage Pit: Distance to nearest well-----------------_----Distance from foundation....................Distance to nearest lot line-______________-- ❑ NJR Number of pits_____________________Lining material-----------------------Size: Diameter---.------.------------Depth------------------------------A.. Cesspool: Distance from nearest well--------------___Distance from foundation-----------------_Lining material----- ❑ N�� Size: Diameter---------------- --- ----------------De th---------------------------------------------------Liquid Capacity gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.---------------------------.------------- Q Distance to nearest lot tlline----------------------- --------------------------------------------------- e ---------------------------------•---_----------- Re d 'ng and/o airing (de cribe):_'t '--� G :. ..... .... .. .�'+_c�--. ..-0..��.�.-t----------- o - - � .w-co -------------------------------------- ------------------- ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------ ------ I here ertify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St to laws, and ru and regulations of the San Joaquin Local Health District. (Signed) - - -- ------------------------------------------------------------------------------ ---.-(Owner and/or Contractor) By:------------------------_------------------------------------------------------------------------------------------------------(Title) -------- ----------- ------ - ------- ------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY v APPLICATION ACCEPTED BY - ------ DATE..---� 5.1_4--------------------------- REVIEWEDBY--------------------------------------------- ---------------------------------------- ------ DATE------------------------------------------------------------ BUILDING PERMIT ISSUED-------------------- E--------------_-- ------------------------------------------- Alterations E----------------- Alterations and/or re�c mme/nda tions ----------------------------------------------- ----- - - -•---------------•••--------------/--/ `.. `•" � i'� •--�-• ��✓.�c �.Q -- -----------••--•----•------------••-----------------•-------------------- -----------1--------------------------------------------------------- ---------•--------------------------------------------------------------•---------------- ------ --------------------•---•-----------------------------------------------------------------•---•----•----------.------- ----•-- ------------------•-----------••-------•---- -------------------------------------------------------------- ------------------ ------------------------------------------------- ------------- ---------------------------- --------------------------------------------- 11------- ---- ------------- ----------- ----------------------------------- --- ---------- -----------------•---•------------------------- ---------.------------------------------------------------------------------- FINAL ---------- -----------------FINAL INSPECTION BY:..--- --------. --------------------------- Date._---- ------y h1��---------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Haxelton Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th street Stockton,California Lodi,California Manteca,California Tracy,California