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,��. !� � mow•:";� 1 APPLICATION FOR` -ANITATION PERMIT Permit No. __ S_ ...... (Complete in Duplicate) i, Date Issued ___.r__�!_-�. .�.) Applica+ion 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. - ------ ---------------------------------••----------------•----..-._..-----------------..._..------ i JOB ADDRESS A LOCATION Owner's Name---- � Ab --------------------- ------------------=------------------------- Phone._-_-- ^_-./. 4.- -• Address---•---•f �� `s-- ,A,3------------------------------------------------------- il' Contractor's Name------ Phone_ _.. . ` t _ -------------------------------------------- ----- b3-- 3--I4 ----' !ip Installation will serve: Residence &/Apartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units:;_k_____ mber of bedrooms 2-_._ Number of baths ..-h___ Lot size -��.__--- - -— 16-0 , _ Water Supply: Public system) Community system ❑ Private ❑ Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe W/Hardpan 0 Previous Application Made: Yes El No New Constr"uction: Yes �No ,❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or ces;pool permitted if public sewer is availa6le within 200 feet.) Septic Tank Distance from nearest well-----------------Distance from foundation--------------------Material----_-__.--_.___.--.___.._________.._____--___-. No. of co`mpartments--------------------------Size------------------ Liquid depth 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 f Iter material----- -------------------Depth of filter material---------------........Total length------------------------------------------ sf Pit: Distance to nearest well (�_. _—------ from foundation___�.�___.._.___. tante to nearest lot I�-_�.__ ___. _ Number of its_-_-_ Linin material___ hl Diameter._ .............Depth.._ __�_____-____.______ p _ 9 CA Cesspool: Distance;',from nearest weld-----------------Distance from foundation--------------------Lining material___.___-_.____.____-_____________- ❑ Size: Diameter------- ------------------ .-----------.Depth----------------------------------------------------Liquid CapacitY---.------------------------gals. . Privy: Distance from nearest well-------------_-------_---------------------------Distance from nearest building.____-____-_.__-____________..._. ❑ Distance to nearest lot line-------- ------------------•------------------------------------------------------=------------------------------------------7------------- Remodeling ---------------- - Remodeling and/or repairing (describe':------ G`{ } ----•-�'---¢- - -----•- -:- - �\ d ------------•-•------------•-------------------- ------------••------••--•--•----------------------------- •-----. --•---•- ------ ---------- -- --- -------- II --------------------------- -------------------------------•--•-----------------------------------------------------------•--------...--•----•-------------------•---------------------------•--•--------- ---- --- Thereby certify-that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances' tate laws, and rules and regulations of the San Joaquin Local Health District. `\ (Signed "' (Owner and/or Contractor) By---- ----- _ I [Plot plan, showing siz ;f lot; location of system in relation to wells, buildings, etc., can be placed on reverses e). II. 1 FOR DEPARTMENT USE ONLY .: .i APPLICATION ACCEPTED BY----- ------ --- -- --------- ---- -------------------------------------------- DATE---------- --------------------------------------- T:. REVIEWED BY--------------------------------- - ---- ------- --- ------:.--------' ---- RATE -\-- W----N-------------------*- ------- BUILDING PERMIT ISSUED.A------------ --- - DATE. Alterations and/or req mmen afion�t. - ----------- --------------------------- ---------------- ------- -- - - a ---------- ------------- ----=------------------ ---------------------- -------- --------------------- ---I----------------- -----------------.-- - ---------------------=--------------- ------------------------ -------------- ----------- --- -------------------------'------------- , ---------------+=----- il -----------------•-1---------------------- '----------------•----• ------------------------------------------------------ -------------------------- ----- --------------------------------------------------- $$ _ 4 FINAL INSPECTION BY..--- --- S___ -- Date ` �r --------•-- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Sheet . '30D West Oak Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California ES-9' 145446 ATWCU.