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FOR OFFICE USE: APPLICATION FOR ANI'ATION PERMIT Permit Na. c _J- --------------------------------------------------------- - ------ (Complete in Duplicate) This Permit Ex fres 1 Year From Date Issued T Date Issued / ._,��2dllk Application is hereby made to the San Joaquin Local Healfh 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 AND LOCATION�� - �J ......... Owner's Name--------- , - ---------- ------`IPhone--- �falo Address----- --- -- ' -------------------------- ------- Contractor's Name------ ---------------------- Installation will serve: Residence ❑ Apartment House E] Commercial E] Trailer Caurt ❑ Motel ❑ Otheros�,�i�/ Number of living units: -------- Number of bedrooms -------- Number of baths ------ Lot size ______________5 - __-_;_____.___. Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Tables- ft. Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy Loam EP' CIay: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 fen -or cesspool-iermitted-if public sewer is available within-200-feet.)— �. - x�n ` Se tic T nk: Distance from nearest wel!---------------- Distance from founds�ion.l�__ ?vlaterfal1�`�'' - � No. of compartments.....=3----------- ____-Size_ _X-5-_, -- -4�__Liquid depth------�V...............CapacityA9.0- Disposal e d: Distance from neares well.................Distance from foundation--------------------Distance to nearest lot line---------- Number of lines:___ __________________._..-Length-of each lirie_�o_ __R.__��_____--Width of french___._�_.(a._-`_____________--. Type of filter material--- l. . _ .e^('_Depth of filter material--_ZO_.-__.----Total length_____ o_® Seepage Pit: Distance to nearest well---------------------- from foundation------------------- Distance to nearest lot line'--------------- El Number of pits----------------------Lining material---------_-------------Size: Diameter--------------- Depth-----..-------------------------- Cesspool: Distance from nearest well-----------______Distance from foundation-------------`___..Lining material-.--.-________^____.'- -- "Li uid Capacity gals.Size: Diameter--- ----------------------------------Depth-. ----------- Privy: Distance from nearest well------------------ -----------------------------Distance from nearest building--_-_...________-.____________..____--__.. ❑ Distance to nearest lot line--------------------------- ----- - -- ----- - ---------------------------------------------------------------------= ----------- Remodeling and/orrepairing (describe) '1 '_'' -_•------------------------ } 4 {. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------- ----------_---------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------....- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to laws, and rule an regulations of A San Joaquin Local Health District. - (Signed)---- ------- -- ------------------------- ------- -- ---- ------------ --- ----- - --------j--- �----- Owner and/orCo- ntractor) '. .,,, -. .,,:- � �- ....mss..,-- ��Y �-� - - {Title)- = --------------------- '�." - (Plot plan, showing sizo�of lot, location of systemin-relation to_.vice[Is,-buildings, etc., can be placed on reverse side). } FOR DEPARTMENT USE ONLY k APPLICATION ACCEPTED BY ------------- jI � DATE -Z- - --Z------------- REVIEWEDBY--------------------------------------------------------- / DATE------- ... -------------- BUILDING PERMIT ISSUED--------------- ------ DATE------------------------------------------------------------ r Alterationsand/or recommendations----------------------- -------------------- --- -----------------------------------•-•---------•-••-----•------------------•----------------- --....----------- ------------- ------ ---------------------- ----------------------------- --------------------------------- e -------------------------------- --------------------------------------------................... t----- -- - ._..-. FINAL INSPECTION BY: _____ ________________ Date----r '.._j- ~� -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazelton Ave. + 300 West Oak Street 124 Sycamore Street 205 West 9Th Street t Stockton,California + Lodi,California Manteca,California Tracy,California F.P.0 O.