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r.W-91k'V' 1 ' -- APPLICATION FOR, _ANI-ATION PERMIT Permit No. "' ".. (Complete in Duplicate) Date issued Applica{ion is hereby made fo the San Joaquin Local Health District for a permit to construct and install the work herein described. Th' a Ali-ation ad in omplia ce with unty prd' ante o. 549 lV1L1��1 �1 �'ti C i .D42 rid o. 549 a nl 8$ JO ADDRESS A D LOCATION___--""""".------_--_-___-_"________-- r (; ---------- Phone-�G------� '� Address °�- .. :. - ----6-`- - ----------------------------------------------------------------------------------------7- --------------------------- Confract-or's ----- Contractor's Namer ----- -- Phone. • . Installation will serve: ,Residence W"Apartment House [] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:"--/----- Number of bedrooms -3---- Number of baths ---t--- Lot size •------I-. C" -".- Water Supply: Publics stem r y ❑' to system ❑ Private 02''bepth to Water Table r _r ft. Character of soil to a depth of 3 feet: 'Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam CCllJay [] Adobe d Hardpan ❑ Previous Application Made: Yes ❑ No 52/'� New Construction: Yes P' No ❑ TYPE OF INSTALLATION AN SPECiFiCATJONVS:"""" (No septic tank or cesspool permitted if public sewer is available within-200 feet.) Septic Tank: Distance from- nearest well- �___--_"Dista ce from foundation--_��_#_ " Material- _. r No. of.compartmenfs------2--------- "_--Size-".":�M-`f- "- --Li uid de th----- 4<-S, e q P. ----Capacity-- oi.4". - Disposall Field: Disfanee from nearest well-_ -- Disfance from foundation_- f��'.�_°_._-.'Distance to nearost lot ine__/ ___�___._ N, "—';J.of.liries=_ _:__j------------------------Length of each line----!!--- V f ---.Width of french------2 " Type'of filter rnaferiai__M-c, ,._ Depth of filter material--_-- s--;-,r ------.Total length------- Q--------- SS 11 C Seepage:Pit: Distance -to nearest-well-.-l--------_-.-Distance from foundafion_.�_ {W.-:.Qisfance fo nearest to Ii i Number of,pits.-_-.__- +___-rLinin 'material" `' Lining' � ,--------.5ize: Diamer_-- 1 - - -- De tn- /_� y -- --------- Cesspool: Qisfance from nearest well----------- from foundation_._______"-_ Linin - -❑�:= : ,Size'Diameter" _ ` g material ...... _. .�Depfh_ -- Liquid Capacity: gals. :. ----- ----- Privy: Distance from nearest well-"=_-...- '____Distance from nearest building � El Distance to-nearest lot line_=.._-_--..-"--.----__-_ g ---------------------- �---- ---------------------- - Remodeh) and/or repairing (describe): -------------------- - •------------ r---.------ , ----•--•- -------------- --------- _- -• -�---��--- - �r � --------- -- - �� V) --------- I hereby certify that I have prepared this application and fhat'fhe work'will be done in accordance with San Joaquin County ordinances, S+ate laws, and rules and regulations of fhe`•San Joaquin Local Health District. (Signed) - -----------------.-----••----------- -------------------------- •�� ..,� `� �_: ' �_ _ - --��.• ---------------------------•- {Owner=enc!/.or,Contractor) RY� - ._-• -x' `�-� - a :r Title ]� ( P g y { ------• -( )- 1' x '1 Plot Ian, showin sized f lot, location-of s stem in relaafion to wells, buildings, etc., can be placed-on rever side). FOR DEPARTMENT USE ONLY APPLICATIQN ACCEPTED BY-----------------------------------_-" REVIEWED BY----/A ------------- Y----/A ------------- - ------------------------------------I---------- DATE ----•--------•---- ' ;: ----- -----y-- --- - � ------- DATE-----------------�..--------- BUILD1NG PERMIT ISSUED----------•---- - - ........... ---------= ----- DATE-----------•:----------------------------------------------- ---------- - Altere+ions and/or recommendations:_"-. '�� - '------- --------------- - ------ -=--------=-I-- - --- {---------- 1, -------•----- -----•---------•------ ------------------- FINAL INSPECTION BY:----- ______"-- --_-_-- Date------------- - Z�!�� -- •-- ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street '� 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-2100