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� - � APPLICATION FOC A'I�ITATION PERMIT Permit No. ...> T ..Z': (Co'Inplete in Duplicate) / ; • „»..--••—�..�-..,,,_.. Date issued ...._ ...S.�.. Applica{ion is hereby made 4c,46 San Joaquin Local Health District for a permit to construct and inst II the work herein described. Th' a Uli:ation je,_ edQ in�somplia ce with unty prd once o. 549 Qe G ��K�i h,;k A S1 C t�.bt21�A•d j t�,V-W 2 e.nl c Q., 4JL L'R•'2 Et n! kQ�-'r. JO ADDRESS AND LOCATION............... Owner's a�e'_.:. >'�. aJ. '�lt!"C�/� ... `_......... s� _.... ..........:.... Phone. �' ... 1 � .._. •-- AddrS ° Contractor's'Name-'. - - •-•L^..`- ..............._-.. --------------- Phone. ^_ ...__..... . . - Installation will serve: ,Residence [�Apa�tment House ❑ Commercial ❑ Trailer Court ❑ M el ❑ Other ❑ Number of living units: Number of bedrooms 3_... Number of baths ..r..__ Lot size --------!! -- i�.. .9✓. e .......................... Wafer Supply: Public system ❑"'Community system ❑ Private [1�epth to Water Table 6n,.r f. Charac+er of soil to a depth of 3 feet: 'Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loa m❑ Clay 3 Adobe EiJ Hardpan[D Previous Application Made: Yes ❑ No R New Construction: Yes No ❑ TYPE OF 14STALLkl;5 I AND' (No septic tank or cesspool permitted if public sewer is available within.200 feet.) Septic T nk: Distance from• nearest well___._.d.......Dist a�Jce from foundation...fd__...:__._.Material. ..................:tl"�4i No. of.compartments..---- c----------------Size.4Y, ->��-.w--Liquid depth_. E'. _ . )- . r e L R Disposal)Field. Distag.ce from .nearest we,l.----_®..._..__.Distance from foundation AA t,..Distance o nearest lot line__ ......... Number-of.lines_.. _L.....__...•.............Length of each line.... -� Width o french__....2...`.�.._-._.----------- Ty ___..-... f_.__... Type'of filter material...6- __..........Depth of filter material....••--. SS Total len th.......s �9---------------- - C Seepage:Pit: Distance to nearist;well�_.1¢�D......___..Distance from foundation-.A4!1 .'C:.Qisfence o,nearest to Ii `.YO- Number of pits.__..:_!._ _.:_..... Lining mMerial�4�.____..Size: Diame er_. .It :. _.Deptn... ii,L� .__... Cesspool: Distance Vom nearest well.................Distance from foundation.....................Lining m terial................................ Size: Dia.meter...-....... = ........Depth•.............---•----......................... ..............Liquid C kpacify.............•---••--------.gals. Privy: Distance from nearest well...............................j .:-.Distance from nearest buil ng... _ ❑ Distance to-nearest'fot line-:.......................................:.............. .. ....•---- ........ ---- Remodel' and/or repairing (describe):.__��.:........................... _^+ - -•----••----- - 3 y .................. y. .....--- ..................... ?--a- :.. /f ...............•----....._....._ .._ .. //�f/� 7� � "��^-iii .l- `•� «........... .. .......... ......... .. _ ._../ •-__..-._._--•• •------------•---...__t--•.... .........`..._._..iy - __-____._.._.._..._.....__..._wr{.�CYS.�..____7_.... .. _'_. _ .. _.__. ..._.. .__..__. ..... .... ..... .... It. 'VI hereby certify that 1 have prepared this application and +ha+'+he work will be done in accordantwith San Joaquin County ordinances, State laws, end rules and regulations of the-San Joaquin Local Health District. r f „ t • - (Signed}.--•��.. _......... ,,; ;,i .-------.-.- ---- •. --•-•------------ r--------------' Owneand/.or.Contraefor) T .r"e•.d ^- _.__ y"':Vi ----_---------- ..� J•3.,,/y •i K _ (Plot plan, showing stiblIf lot, location of system in rela�tioh to wells, buildings, etc., can be placed-on veAA side). ` - FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED SY............•...................... .................................................................. DATE--•-•....................................................... REVIEWEDBY........A.----------•----•-----•-•--..x....-..•------•--•---------------•---•-----------...----------•---------•---------- RATE--•-------•- :-..._..--------------••-------...----------• BUILDING PERMIT ISSUED -•----......-•-•------•----------------•--•--••----•-•- DATE.._..........--- -"-•--------•----•-..........I....•••. ---- Alterations and/or recommendations:................I............ .-{ 3, -............ ...................:...................................---•-.............................--------•-•-----•--------- FINAL INSPECTION BY:.............__-.. _ - ............. Date................ --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Anserlean Street 300 West Oak Street 132 Sycamore Street 814 North "C"Street Stockton, Californla Lodi, California Manteca, Califamle Tracy, California ES-9-2M Revised W-2100