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' r ANlTA7lON PERMITNo. APPLICATION FORS Permit .................. ... (Complete in Duplicate) Date Issued ' - __,111IT4 f 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.. ; JOB ADDRESS AND LOCATION.... Owner's Name •:-_- �------- - ------ --j- ------- r - -._ Phone ---- •- - � )... _ -------------------- --------------------- ------------------------------------------ iS .�}�,, � 9� �- ---- ------------------- - -•--------...---------•----------------•-- t - /'.J_ - - -- ---- ---r--------------------------•------------------ Phone---------------------------------•• a Contractors Name__________________ __ , Installation will serve: '.Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other : Number of living units: -------- Number of bedrooms -------- Number of baths size ----- -- ----------------- r Water`Supply: "Publicsystem Corrimunity system E] Private ❑j 'Depth to"Water Table -------- ft. " 1� Character of soil to a depth of 3 feet: Sand L] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ .:Clay ❑. .Adobe Hardpan ❑ Previous Application Made: Yes o ElNew Construction: Yes [A -6-0 TYPE OF INSTALLATION AND SPECIFICATIONS.- (No PECIFICATIONS:(No septic tank{or cesspool permitted if pubic sewer is available within 200 feet.) lstance ro foundation_ - __0 Material__-________ --( .--` Septic Tank: Distance from nearest well-_-__.-4�'rD' �p� - l -- No. of compartments --.-.-=Size__.____ 'T-�`' iquid d pth____-__ .- Capacity___ 1 �: � i • . d Disposal Field: Distance from nearest well_____ _________Distance from foundation__--__:_-___,_4___.Distance to nearest lot line----------------- Qj ❑ umber of.lines_ _---------- Length of each li Width of trench Type or' filter material-------------------- ----D iter material------------ -------Total length-- --------------------------------------- epageJF'if- � Distance to nearest w`ll _ ________--Ddstance from foundation------..______:.___.Distance to nearest lot cine______.___-__-__ ! ❑ i , Nubmber of,pits-------= -----------Lining material------------------------Size: Diameter-------------- ---Depth- --------------------- ------ Cesspool: Distance from nearest-well-----------------Distance from foundation..________-_`----.Lining material________________________-----._-_-._. Size: Diameter.- ' :-iDepth = ---------- ----------------- ----Liquid Capacity----=----------------------gals. ----------- Privy-...sDistance from t arest well-------------------------`----------------------.--Distance from nearest building----------------- •-•------------.------ F ❑ k., - . 7. _, ,. ... _ - -------- --------- --- Distance to nearest`{ot�line-"_'A`------.------------= ----------------------•----------------• -------_------------ Remodeling an•d/or repairing (describe):-------=-- ------------------------------------------------------••-------------------------.-•--------------------------------------------•--------- i l __ .. ----------------- ----------------------------------- ---------------------- + I'hereb certify-that43 . h e. re ared this a hcafio = yp P pp n and chat the work will-be done in-accordance with San Joaquin County ordinances; State-laws t and =rules and regulations of the San Joaquin Local Health District. .I - -------------------(Owner and/or Contractor) (Signed '. . ) ------ I By:--- -- ----- -F---- -- ---------'•---------- -----------------------------------------(Ti# (Plot plan. s owing sire of lot, location of system in-relation to wells, buildings, etc., can be placed on reverse side). x FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- ----------------•------ DATE--- _7�5y--------'--- DAT E-------------------- REViEWED BY--------------'--------=-------- ,-------------------------------------------_.-------------------�------------------------ ---:-----------------:----------------- BUILDING PERMIT-ISSUED------------------------------------------------------- -- --------:-.----------------- •----------- DATE ..--------------------------------- --------------:--------- Alterations and/or.recommendations:- _ ---_ ------- ------------------------ ----- ----•--------.-.-..._.---•------------- 1 -- — ---•- --------------------------------••- o ' - -----•----------------•--------•-------•------ ------ ---------- i . . .t --------------------------- ------------------------------------'--------------I------- I ---------------•---•-------------------------- -------- r I i -------------=-----=---------- FINAL INSPECTION BY::-----_..a; ----- "-W•'"" ----=- --- ` Date- r =-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California •Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100 .-