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j APPLICATION FOR ANIYATlON PERMIT Permit No.'..t�_ �.. -.... (Complete in Duplicate) Date Issued Applica+ion is hereby made to the San Joaquin Local Health District for a permit to consZ and install the work herein described. This application is made in compliance with County Ordin nce No. 549. JOB ADDRESS AND LOCATI _, P±. ._ .......... .... ........... 1 Owner's Name._ hcjne----------.�---------M i / ... T .-_ :------ • •------- -• . - - - '____ Address____..��._}l 'h �_._.. Contractor's Name.-- --_ - _---_-• ._.. ...�... --- Phone................._.__.__..._--.._. Installation will serve: Residence{ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __L.__ Number of bedrooms�. Number of baths -_/_-_ Lot sae ..,.e." _.�C.. C .-.P ------ Water Supply: Public system ❑ Community system ❑ Private ( Depth to Water Table /.. _ ft. ; Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ Adobex Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septicrtank or cesspool permitted if public sewer is available within 200 feet.) Sept' Tank istance from nearest well.................Distance from foundation.__-_---__..........Material....._,...__._____.._..._.._._..._--___-________. o, of compartments.......................! ----•------:___Liquid depth-_..,._.__..............__Ca aci •� • Size................. P tY•----•-••--•-•-------7C Disposal Field: Distance from nearest'well.._._ ._Distance from foundation j...'.e.__.._.Distanee to nearest lot line... ._._ Number of lines____________ __ Length of each line_____ -'-------.Width of french........2:! ........-,....... Type of filter material_ •De th of filter material....J_e�............Total ____________________ Seepage Pit: Distance to nearest well......................Distance from foundation....................Distance to nearest lot line................. ❑, Number of pits......................Lining material___.----•---_--_--:---Size: Diameter-----------------------Depth....................... Cesspool: Distance from nearest well_________________Distance from foundation...............___-Lining material....................._................ . ❑' Size: Diameter------------------------- - - -----.,.Depth--- - ............ ....................... paa :Liquid Caty----- ----------------gals. _.. Privy: Distance from nearest well--------------------------------•-------------•--Distance from nearest building_ ,___-........._._._._...___________._ 171 Distance to nearest lot line----•--------- ----••------...__._..._._..-....-•-------- ---------------------------------- •....................._.................. ... • r Remodel' q and r reg ring des rib :. ' pltli_ n�.�.stt. ± .� L�Q ' r .... - .:_--- 40 fQ . , . I herebycertifythat I have prepared this plication nd that the work will be done in a brdance with San Joaquin County ordinances, tate las, and rules and regulations of the San Joaquin Local Health District, t i (Owner and/or Contractor) (Signed)_ ------------------•------•---•--•-----:_.:.,.....----.-........---•--- ......_-...------_....._...----------•----.._ -----•--- �( ,, '''+;,.," ^r•.. -----------------------------------(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 APPLICATION ACCEPTED BY................-................... -------- --- DATE—_--—---------_----- ............................. REVIEWED BY _... ............. DATE_._...:-_------_-_•.._--••-----•---------------------------- BUILDING PERMIT ISSUED._. DATE....:.................._.._.... .. - --._...-•-----•- Alterations and/or recommends ons:.. _ __ __ _ __________ _ Y •-••-- -•-•••••• -••- ------------ ---- - �� f9 --------- --_.. ,. ----••--- .............................. ---- FINAL SPE TI N BY:..... ---------------•-----_.._...------._..-_... - Date---.............. ........................... ......------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Skeet Stockton, California Lodi, California Manteca, California Tracy, California