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APPLICATION FOR ATATION PERMIT Permit No. ___ (Complete in Duplicate) Date Issued .-_._,!s_ . I_ 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 com pliance.,with County Ordinance No. 549. `k--JOB ADDRESS AND L TI N-------.14�------w----- 6-_-------------------------------------------- Owner's Name------- -;---------` ` = '=`--------- Phone-Av---• �_`� 4'-1.---- Address-------------------- rI =---- --------------`r------------------------�--. •--------------------_------------- Contractor's ---_-- ----- -----Contractor's Name--- ------------ -------------------- Phone--by-- 3_./Yky Installation will server Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ _-._ Number of bedrooms _- _ Number of baths ----- Lot size ___ -f' Water Supply: Public system[❑" Community system .❑ ' Private ER�Depth'to Water Tables_ ft. Character of soil to a Idepth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe [Hardpan ❑ Previous Application Made: Yes ❑ No Rl" New Construction: Yes 2"No ❑ FHA/VA: Yes ❑ No ©. - TYPE OF INSTALLATION AND SPECIFICATIONS: # w (No septic tank or'cess"iool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest-well__�_Q'_..____Distance from f Bund tion__1_6---_--------Material-_�rn � r em✓ --___-i9 y No. of.compartments--____°�---------------Size_H_ 4__�Y_�`t._-_Liquid depth-.=3-_-1•_._3--_------Capacity---- 4_x-U/- Disposal Field: Distance fr'•om nearest well ------ Distance from foundation--------------------Distance to nearest lot line------------- 0 ❑ Number of lines-------------- Length of-each line------------------------------Width of french---------------.._-___------------- i Type of filter material----------- __.Depth of filter material_____________________._Total length___.____.____-_-_,_----_____________-_____- Seepag`e,.Pit: Distance tq nearest w I`_'( Dl ft, from foundation--��°v1� i----.Distanccee oto,;nearest lot line__ "+_.---_ [v� Number of pits------1-----____ Llnl materlal__�� Size: Diameter____ _��_ Cesspool; Distance from neaiest well-----------------Distance-from'foundation-------------------linin ma ,. , Perial-t __.____.-____-.______-____4_--_-___ ❑ Size: Diamleter___-____.-_____--.__------'-___..__ De th_4-_--_-_----- -_--_ - - -_--__Li Liquid Capacity - ----gels . Privy❑•- from nearest well---------------__.._°-------------------------Distance from nearest building--------------------------------__ Distance o nearest lot line------'----------------'-;�,wi---- <----� �_-•---------- ------------_'.,----- -' I L _ Remodeling and/or repairing .(describe) - a .. --------•---------------- - -------------------- IM 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, and rules and regulations of the San Joaquin Lacal Health District. (Signed) S ' (,Owner and/or Contractor) gY•----------------� ----------- ----------------- ----------------------------------------------------- (Title)-- ------------9-1 plan, showing size4 lot,:,:,location of system in relation to wells; buildings, etc., can be placed on reverse side)..e. FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BA_� ={ i ---- -- '_--------- DATE-7� REVIEWED BY-------------------------- --------------------- DATE ` ~. --------------------- BUILDING PERMIT ISSUED-----=1-- - ---------------------------------------�--•----------------------- DAT ---- -------- Alterations and r recommend ~ ations- -- --- ------ ----------- ;= -------- ------- ------------------------------ --------- --'-- --- ------------ -- -- ------ -- ----------------------------------- ----•- -- --- ---•------ --------- - -------- ••---- --------- --------- -------- --- ----------------- FINAL -FINAL INSPECTION BY:..' V------ •----------------- ----------------- ---- Dat -- -- ---- -- ------------- ----------------- SAN JOAQUIN LOCAL EALTH DISTRICT 130 South American Street 300 West OakStreet 132 Sycamore Street' 814 North "C" Street Stockton, California II Lodi, California Manteca, California Tracy, California �I. ES-9-2M , Revised )-57 F.P.Co.