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:• APPLICATION FOR ...,N ATION PERMIT Permit No $'�.F� ,`-_---- (Complete in Duplicate) Date Issued Applica}ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. its application is made in compliance with County Ordinance No. 549. a JOB ADDRESS A LO�CA�T'IOON.-•---•-(7- Ot q `'� `'s' -------------------------•-----------------•---- ------- y Owner's Name. MrA �- '!�'�-------------- - Phone { r� ---•----.--- - f Address... "�. ._l.l..r ---&-----L-I... `'°"- ''��`� ---..... Contractor's Name--�-------------•------ - ---------•-------- PI,one --•• ------ Installation .f' Installation will serve: Residence I2" Apartment House ❑ Commercial ❑ Trailer Court [j (t9 I E] Other E]` Number of living units: .____ Number of bedrooms . Number of baths —1- Lot size .,_. ..._.._I 1-6,0----- ----------------- Water Supply: Public system ®''"Community system El Private ❑ Depth to Water Table`.>�__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g, Hardpan ❑ Previous Application Made: Yes ❑ No F"�' New Construction: Yes U�rNo ❑ _- TYPE OF INSTALLATION AND SPECIFICATIONS: {. (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well .:..............Distance from foundation--------------------Material....-_-__._..__.----_---_---._-.---------.---- No. of compartments---------- - -------------Size--------------------------------Liquid depth-------------------------.Capacity----------------------- DisposalieId: Distance from nearest well---.-------------Distance from foundation.--_-__--.......__.Distance to nearest lot line-------.._.- Number of lines--------------------------------- -Length of each line---------- ------------ ---...Width of french.---------------------------------- TYpe of filter material-------------------------Depth ofilter c. it er material------------_---------- otal length--------• ------------ ----------- -------- Seepage ------- Seep ge Pit: Distance to nearest well - .--_ ___Distance frofoundation__ Distance to nearest lot _5.....____. ine ---3 `umber of pits---1-----------------Lining material- Size: Diem er Depth "U i O �.Cesspool: Distance from nearest well-----------------Distance from foundation----- .........-....Lining material------------------------------------- ( t Size: Diameter----------------- --------- ----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. ❑ ..._Distance from nearest buildin t Privy: Distance from nearest well ----------------- -- -------------- 9------------- -------------------------� ❑ Distance to nearest lot line---- ----------------- ----------------------- ------------------------------------------- ------------------------------------ ------------- Remodeling and/or repairing (describe):- - -------• --------- -7-ti U----------------------------- 1 1 ------------- ------ -------- -- ------------------------------------------------------------------------------------------------------•-----•-••------------••--------------------------------------------------------- ---.. ------------------------------ ------------------ -------------•---------------------------•-•------------•--------------•-------•-•------------•--------•-------- --------.------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County j ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. - Si ned {Owner and/or Contractor) • F. . I @ � - --- -- --------- {Ti+lel f Y== = -7------------------------------ ---- plan, showing size lot, location of system in relation to wells, buildings, etc., can be placed on reverse ide)2n FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ -------- DATE�.�" --- ----------------- REVIEWED BY = ------ DATE__ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------ ----- DATE...._. . - .-__------------------- -------- Alterati ns an /or recommendations:------- ------------------------ -------- ---------- ----- •--- ----------- � .. ,f --------- - -- - --- = `tI '-€'- --- ��` � FINAL INSPECTION BY::._ :. Date------ F. SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i ES-9 145446 ATWOOD