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FOR OFFICE USE: - 4 _ _-i- ------------------- / fd - --------- '-------------------------- - ..... APPLICATION FORANITATI4N PERMIT Permit No. ...-- -.. .......... (Complete in Duplicate) Date Issued ------------ This Permit Expires 1 Year From Date Issued -- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. r This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-_- -------- ----------X--------- A.......... �---�Phone_ ---------------------- Owner's Name----------------• ------• �3 Address. ----•------------------------------•---•----•----•----.......-------------------•--- Contractor's Name-------------------------- •-•• ------------------------------------------------------------------------------------------•--------------- Phone................................... Installation will serve: ResidenceApartmentApartment House E] Commercial E] Trailer Court E] Motel [3 Other Number of living units: .__1___ Number of bedrooms __�_--- Number of baths __j--- Lot size =__.__ _ "_ ._: :`�-..��1/ Water Supply: Public system Community system ❑ Private ❑ Depth To Water Table/?I)_- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: (If yes,date.___. _.__ _._:___} No New Construction: Yes [] No.�FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer .s vailable within 200 feet.) Septic Tank: Distance from nearest c f m foundation____________________Material _____._______._.____.________.-...._...._______.. ❑ No.,of compartments_____________ ------ 2e------- ----------- -----------Liquid depth--------------------------Capacity-------------•-•------ �ispo a I �� D' tante from nearest frest well_ _ _ . _____Distance from foundation____�_1.....Distance to nearest I t li a f '( umber of lines-.-_-- I------------ - -Length of each line-------..__l.l1_if......Width of french-------�------_.. .-..._._ ypa of filter materia -_ _Depth of filter material ._._r4=____ __-_-Total length_______I_!.?-�____________________ Seepa rt: Distance to nearest well'-____ ---------Distance fro foundation___!Q_�_.__..Distance to nearest lot line...... � ._.Number of pits___!.1--------------Lining matanal_ __ _.___ _ - ize: Qiameter__._._2- ........Depth----- y��-.� �f Cesspools Distance from nearest well-------_--------_Distance from foundation---_----------------Lining material------------------------------------- 13 Size: Diameter-----I--------------------------------De th---------------------------_ ---------------------Liuid Capacity gals. Privy: Distance from nearest well_.---__-----------------------------------._.__._,_Distance from nearest building------------------------.____..__._____._. ❑ Distance to nearest lot line------------------------- ---------------•-------------------------------------•----------------•--------- ----- .... C Remodeling and/or repairing (describe_______ ..L ---------------------------•-••------------------•-----------•---•----••-----•--------•----------••--••---------- •---------------------- j -----------6-I --------------------15� o-�� *-----------......-------•-----•---•-----•----•---••--- •------------ i ----------------------------------------------------------•-•-•-•--------------------------------••--------------------- --------------------,-----------------------------------------•--•-•---------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ! ordinances, State laws, a d rules andjregu tions of the San Joaquin Local Health District. (Signed (d__..r A -4f— ---_- ._ -------------------------------------------------------------------------------------------(Owner and/ BY: ' ,-=----•-'--------------------------------•----------------------------(Title)----------I----------------------------------...._._---------- (Plot plan, showing size of lot, location of system in'relation to wells buildings, etc., can be placed on reverse side). ( FOR D PARTMENT USE ONLY APPLICATION ACCEPTED BY ------------- ------------------- --- DATE------ f/ REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------.. DATE-----------------._..... BUILDINGPERMIT ISSUED------------- ---------------------------------------------------------------------------------------- DATE---------------------------------------------- Alterations and/or recommendations:---------------------------------------------------------------------------------------------•-•--------. -I ..._.. ---------------------------•--•-------....---------------•-------__.----------------•--------------------------------••----------------•------------------•-----------------------------•-------------------•------------ I 1 FINAL INSPECTION BY:_.. s.. ------ ----- Date-------- ------�'R� f fr - 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street y 124 Sycamore Street 205 West 9th Street Stockton,California i Lodi,California Manteca,California Tracy,California ES 9 REVISED 8-59 2M 5-62 ATLAS