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'FOR OFFICE USE: ---------------------------------------------------- APPLICATION FOR %AN11"ATION PERMIT Permit No. I-/,....... ........... ------------------------------------------ ........... ..... --------- 0 (Complete in Duplicate) Date Issued This Permit Expires 1 Year From Date Issued ................ - -------------------------j Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Th.is. application is made in compliance with County Ordinance No. 549, t — JOB ADDRESS ANCATION---------------- ------- ----------------------------------------- -------------------------- P jp Owner's Name-------- ----------f---n---------------- ----------------------------------- ---------------------------------- ....... Phone----------------- ......---------- T- Address---------------------- 4 b /10---------------------------------------------------------------------------------------------------------------- ,4 Contractor's Name----------------- a(----- ----------------------------------------------------------------------- Phone----------------------------------- installation will serve: Residence V--Apartment House E] Commercial F ] Trailer Court El Motel ❑ Other ❑ Number of living units: _ __ IN ber of bedrooms`]-- Number of bath;/___"_. Lot size ---------------------- Wafer Supply: Public system 61- C' Iumm,,uriify system El Private El Depth to Wafer Table ff. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam 0 Clay E] Adobe A--�Hardpan 0 Previous Application Made: (If yes,date____________________) No �ew Construction: Yes E] No A/VA: Yes 0 No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) S t' Tank: Distance from nearest well------- - - ------Distance from foundation---------j---------Maferial-------------- --------------------------------- Tic . S —, Iy (577 -, ) No. of compartments--.-----------------------Size--------------------------------Liquid rd,pth----------------- ------ -Capacity------------------------ Disposal Field: Distance from nearest well '--.-Distance from foundation___ Distance to nearest lot line----4-----/----- Ah IOJZ`S�- -.&—Number of lines---------I r Length of each line---. --i%-4 _/-.Width of trench____D ---------- Type of filter material- --epth of filter material------ length-!PS7'�- -Ir------------------- Seepage i : Distance to nearest well------—-----Distanc%n)orn/Foundation--_/_Q_/_.---.Distance to nearest lot line...�v...... -VI ----------- 0'"^71umber of pits--------- ----------Lining material C. Size: Diameter-.?3..9---------Depth_- --- - ----- -------- Cesspool: Distance from nearest well-----------------Distance from founclafior....... ...........Lining material_..._---_-------.--.--_-.---__--___ 1 aterial-----------------------------------11 ❑ Size: Diameter--------------------------------------Dept h-----------------------------------------~----------Liquid Capacity-------------------------•--gals. Distance from nearest well-------------------------------------------------Distance from nearest building--------____..._____.______._._ -- I�Privy-. -- ------ Distance to nearest lot line.----- ------------ --------------------------------- --- El ---------------------------------------- ------------------ ...... �01 W 4- W�-- .... Remodeling and/or repairing (describe):----- --------- - ----- --j. 6 ------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------ --------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- ------:------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- -- --------------------------------------------------- ---------- I hereby certify that I have prepared this application_and that the work will 6e.,4oq_q in �accordance with San Joaquin County ordinances, State ILw*90 and rules egultions of the 'San Joaquin Local Health District. " (Signed)_____________ ---- - - ------- ----- ------------------------------- -------------------(Owner and/or. Contractor) ------------------------------------- By:---•---- --------- -- ------------- ------------------------------------(Title)---6.4,v.AAAo- ------------------- (Plot plan, showing si lot, location of system in relation to wells, buildings, etc., can be (placed on reverse side). ► 9R DEPARTMENT NT USE ONLY -------------- APPLICATION ACCEPTED BY-5-_.__ -;V. ------------------------------------- DATE--------4-1-- ------------ - ------- REVIEWED BY------------- ----------------- -------- DATE-_ BUILDING ATE--BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------------------- Alterations and/or recommendations------- -------- ----------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- -------------------------------------------w��----------------------------------------7------------------------------------------------------- ---------------------------------------------------------------- -------- -- ----------------------- ------------------------------- ------------------------------------------------------------------------------------- -------------- --------------------------- -------------------------------------------------------- ------------------------------------------------------------------------------ -------------------------------- ---------------- ---------------- ----------------------------- O . -------------- ------------ - ----------- --- -------------------- -------- -------------------------------------------------- - FINAL INSPECTION BY:....�. ---------------------- Date. -------- ..............-- --- -- ------ ---------------------- SAN JOAQUIN10CAL HEALTH DISTRICT IV -,? \ k�,l 1601 E.Hazelton Avo. 300 West Oak Street 124 Sycaniore street 205 West 91h street Stockton,California Lodi,California Manteca,California Tracy,California