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.:4 APPLICATION FOR SAID.,. -. 'ON PERMIT (Complete in Duplicate) Date IssuedI.L--_-2 �- iE Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. I This application is made in compliance with County Ordinance No. 549. JOS ADDRESS AND LOCATION--"_- 30-5-0-.OSD / - ...... --------------------------------------------------------- Owner's Name------ =` itJ r�- ��JF_S.L_ -----------------------------------------•-------------------------------------- ------------ . --------------•------ --- x — Phone"--T_- Address ---------- �.S`�-.S � - a t i ------ - - � r• -'--- .---- I----------------------•--------•-------•------------------•• - ----•-•------------------------------ Contractor's Name-�-----••--•-------------------•---- ------------- • - ----- - -----------------------••--- Phone E Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ' ❑ Motel ❑ Other Number of li!ing units: _1Number of bedrooms -------- Number of baths ---t---- Lot size ___ i Wafer Supply: Public systemCommunit system Y Y ❑. Private ElDepth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel i ❑ ❑ Sandy Loam [[] Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ NoA New.Construct ion: Yes ❑ No 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 __Distance from foundation___.___________-_,Materia!_.__._.------------------------------------------ --_----__-.- _ - ❑ No*.of compartments -------------- ----Size Liquid depth- ----------------- s q p ------- ------- - Capacity-------------------- Disposal Field; Distance from nearest well_- ---------__-.Distance from foundation---------- ---------Distance to nearest lot line------------ .__.. ❑ Number of lines-- -------•----------------------- -------------- -Length of each line------------------------------Width of trench_.___________ Type of filter material-------- ___"._.__ Depth of filter material--_..- t. . - ---------Total length --- l� Seepage Pit: Distance to nearest well---------------------- from foundation-_ -.___.____ vV .-----.Distance to nearest lot line_________________ Q ❑ Number of Pits....-"---_-------____Lining Material ----- ---.Size: Diameter---------- ------:- ---Depth-------------- - Cessp al: Distance from nearest well -"_-Distance from f _undation---� - ' Size: Diameter - _'t'--------------Depth ,� Lining material _ .� ... - - - �p- ------------------Liquid Capacity.. --------- --- gals. Y � Privy: Distance from nearest well------------------------------------------------ Distance from earesf Distance to nearest lot line-- g ------------------------------ __ ___ qQ-Remodeling and/or repairing (describe)_______ _ -- --•------ ------•-----•------------•-----•----------------------•- - - -- -- - ---------- -------------- I •-------------------- Y ! p P -------------------------------- 1 ---------- - I herebycertif that l have prepared this application and that the work will be done in accordance with San Joaquin Caun- ordinances, State lawsand rules and regulations of the San Joaquin Local Health District. (Signed)---------- - r - ---------------------•--------------------------------------------------(Owner and/or Contractor) - --------------------------------------------------(Title)------ (PIo# plan, showing siz of lot;coca ion of sys+ern in r�ela ion to wells, buildings, etc., can be placed on revere side). ----------------------- f FOR DEPARTMENT USE ONLY- 1,A z s t � APPLICATION ACCEPTED BY-../ # ------------------------------------------------------ REVIEWED SY---- i DATE - - � ATE I�-:"tom=-�-�------------------ ------------------------------------------------------- -------- 8lJILD1NG PERMIT�ISSUED__ i S i ------ - - ----------- --------- Alterati ns and or reFommen tin -_ - ---- ---..---• -- 4 . ----�----- 4- - - ._ �.. -- - , �_- O N C,1 ate SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C" Street Lodi, California Manteca, California Tracy, California 4 ES-9-2M 10-52 Revised W-2100