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s APPLICATION FOR ...,NITATION PERMIT Permit No. .----•.�_l.....----- / (Complete in Duplicate) �1,2? �- elAir Date issued _______plica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. "his application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-------1- bLAJG - ------- T -- ----------- Phone. �R_!7. Owner's Name._..-J_Q��h-----�....�'_�o�-�------'"--�--�-'S-R- �-�--- ---- --------- --------- --�- --- Address--------. .b.a ------------------------•- dAa Contractor's Name' i +�-5� -•------------------- Phone. ` Installation will serve: Residence ❑' Apartment House ❑ Commercial ❑ Trailer Court ❑ Mptel ❑ OthgMf ❑ Number of living units: __!____ Number of bedrooms ___Z__ Number of baths ___}___ Lot size .__ �'-i_____--_.l__�.`��_-------------------------- Water Supply: Public system Community system El Private E] Depth to Water Table -- ft. Character of soil to a depth of 3 feet: Sand ❑�, Gravel ❑ Sandy Loam ❑ Clay Loam ElClay ❑ Adobe Hardpan 11Previous Application Made: Yes ElNo New Construction: Yes M/�No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if, ublic sewer is available within 200 feet.} Septic Tank: Distance from nearest well __.a -1?._____Dist nceifrom fouidation-_fid___.._.-____Materials_____P" r'+ ____- ------ j., No. of compartments----Z_..____---.-.--_5ize :�" -_"4-- -- ----------Li uid depth_3_°f -� --------.CapacitY.--- - - q A r Disposal Field: Distance from nearest well_ .'.Q�----Distance from foundation_A1�L.e-_.__-.Distance to nearest lot J`n�e__�_________. ®' Number of lines-----A----------------------------Length of each line------- Width of trench---- -ZL�------------------------ ,,` � � ,. w Type of filter material._."v-J..�.____ -__._Depth of filter material-------�_g__.___.__-Total length--------_-_�____________________________ from foundation_. .___..Distance to nearest lot line__.._____ Seepage Pit: Distance to nearest well. q q-__ _ Distance �� Number of pits_--%-----------------Lining mate ria l__i 4-tyi..______..Size: Diameter----3-�-------------Deptn- .. ............... Distance from nearest well_________________Distance from foundation -----------------Lining material_______..______----._________._.____. �. Ir ElSize: Diameter--------------------------------------Depth--------------------------------- --- --------------Liquid Capacity---------------------------gals. ' Privy: Distance from nearest well-_--- ------------------------------------------Distance from nearest building----- .---------------.---------------- ._. ❑ Distance to nearest lot line------ ------------------------------ --------------------------------- -------------- ------------------------------------------------------- j Remodeling nd/or repairing (describe)---------- ---------- ------- �ru�.u- ..--- -----�--•--- •----------- box--- ----------•----------- --------Y_____ __ _b_________-____--________._____._________.___________-___________.-_.-___________-_________-__.__-_____._________________________.-....--_-_________________- ________________________ ---------------------_--------------------------------------------------------------------------------------------____________________________________________________________________ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County nrdina�n0State laws, and rules and regulations of the San Joaquin Local Health District. 1 s (Signed 1 ------------- -- (Owner and/or Contractor] �Y� �" Q'l .l � ._ -------------------------- [Title) = __ Plot plan, showing size of t, location of system in relation to wells, buildings, etc., can be placed on never side}. [ p f FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------------- -------=-- -- - ------------ --------------------------------- DATE---------------- REVIEWEDBY----- ------------------------- -- ---- ------ __t----------------------- ----------- DATE---- BUILDING PERMIT ISSUED----------- •---- ---- - - DATE C Alterations and/or recom�nenda�tions' ------- - ---------------- -------- _ C (�j-. _._�. ----------________________________----------------------------____________________________________________________________________________ ________________________________ _______________________________________________________________________________________________________________________________________________________________________________ FINAL INSPECTION BY:-.- - -r. r -----------------•----- Date-------- ✓ -------------------------------- 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 145446 ATWOOO