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FOR OFFICE USE: ' T 11 Permit No. - APPLfCATION FOR �ANI 'ATION PERMIT (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.. This application is made in compliance with County Ordinance No. S49. I JOB ADDRESS AND LO ATION _____- --- _ Phone__ _. .__-� � .. Owner's Name_________ _ --- ------------------ ---------- - Address-_..--------- --••-- -------- ----------------- ------------------------ -- ---------- Phone --- --- Contractor's Name___ - ---------------.�_ " Motel Other Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer vert ❑ - / 1 -------------- Number of living units: ---/ Number of bedrooms _�- Number of baths __/_ Lot size ____..__ Water Supply: Public system� Community system ❑ Private ❑ Depth to Water Table _ l ft. r Cj Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,ly " Hardpan Previous Application Made: (If yes TYPE ) No New Construction: Yes No ElFHA/VAS Yes El No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted'if public sewer is available within 200 feet.) ' p Septic Tank: Distance from nearest well__ ___Distance from foundation_ _ Q___.____Material_____ - - t - - -- Capacity_i__ -oil No. of compartments---------0------------Size-- _ -Li uid e t - / p------ __'________. --------- Disposal Field: Distance from nearest well Distance from foundation-__ __ _ Distance to nearest lot line I -_ Length of each line_______.... -`____._.Width of french.......A------------ ------------- �I Number of lines___.______l__-_____ - nn � - --- P Type of filter materiaf'__.1 . -----Depth of filter material..__/ --`�_" Total length______.-P-- --------------------- �J / - -- -- Distance to nearest lot line---.------ Seepage Pit: Distance to nearest well__fr___--------Distance ro ou dation___ ____________. _---Linin material___-� -- Size: Diameter__�_7_�r.-__-Depth_...��_�-------------- t Number of pits_--.___.�__ -:__ g Cesspool: Distance from nearest wel!_________________Distance oundation----------------- Lining material__._._______--_.__-.----------_- h ❑ Size: Diameter-------------- --------- ------Depth__.:---------- -----------------------------. ...__Liquid Capacity_ ---------------- _41 --��::_ _.gals. �.,.: V d-�-... --�� •�-"�` --Distance from nearest building--------------------------------- Distance ______ _________ rivy. Distance from nearest_wel---------------------------------------- 0 ___ ❑ ---- -- Distance to nearest lot line______________________________------------------------------------------ j Remodeling and/or repairing (describe):_-- ----- ----•----------------- ---------------------- ----- --- - ...... --- - - ard'inance565tcert ate tlfy awsh andhrulespandaregulations application the San Joaquin Local Health heDistrict. n accordance with San Joaquin County __{Owner and/or Contractor) (Signed) ---------------------------------------------- -------- -------------- . .--------------------------------------------(Title)----------------------------------------- --- ------ (Plot plan, showing size of lot, location of syst in relation to wells, buildings, etc., can be placed on reverse side). / FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_.__.•_ - - REVIEWED BY DATE------ .." fr.:_t ---- ---------------- ' --------------- DATE-------------------------------- ----------------------- --- DATE-------------------------- BUILDING PERMIT ISSUED------------------------ - - ---F----------------- Alterations and/or ecomme at ns:._ ------___..____ ------------------------ -- -- ------- ----------------------------------------------------- - �_ 4 � - ------------ — . �" -------- --- 41, a - - 4 .._ - r Date--------' =��= �f......... -------------------------------- FINAL INSPECTION BY:"'_______________`-- ----------- --------•------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1401 E.Ha=alton Ave. 300 west Oak Street 124 Sycamore Street 205 West 91h Street Stockton,t;aliFornia Lodi,California Mantecar California Tracy,California F.P.CO.