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APPLICATION FOR -.-%NITATION PERMIT Permit No. <br /> (Complete in Duplicate) Da $sued Y-�,(A)__ <br /> ti <br /> Appliceion is hereby made to the San Joaquin Local Health District for a p rm f onstruct and i tafVfhe wor0herein cl.es'cribedl. <br /> ,r a T f Aonstruct <br /> ov <br /> fphisapplication is made in compliance with County Ordinance No. 549. <br /> 04 <br /> polo <br /> 6 <br /> JOB ADDRESS A LO Tl( ------ ---------- <br /> --- ------ --- <br /> -----------------------WP---------------- <br /> Owner' __._I.. ------ -Y <br /> s Name------ --­--------------- ------------------------------ ----------------.,Phone <br /> e- <br /> Ac[dress......... -----------­---- n ....... <br /> __F---rt5/_V_ _A`ad- --- <br /> Phone- ---- <br /> -------------------------------------------------------------w------------------------------------ --------- -- ----- <br /> Contractor's Name.--- tia _-- Phone � .,� <br /> Installation <br /> ame------ <br /> Installation will serve. Residence VApartment House E] Commercial. [3 Trailer Court E] Motel 0 Other <br /> Number of living units: --t_-- Number of bedrooms Number'of baths .--t_._ Lot size <br /> - _________________________ <br /> Water Supply. Public system El Community system [I Private Q,-16epth to Water Tabl ft. <br /> Gravel E] Sandy Loam ❑ Clay Loam [j 'Play E] <br /> Character of soil to a depthe of 3 feet: Sand JZ Adobe 2/"�H a rdpan 0 <br /> Previous Applicationa es�F] IN 0 es <br /> .M 2?( New Construction: Y [eNo 0 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> '$iiiited if pu lic sewer is available w'ifhin' 200 feet.) <br /> ���(Nosepfic tank or cesspool per <br /> �N, <br /> tic- t f f d ----------------- KA2ferial <br /> c 0, <br /> ani. Distance%from,nearest,well---.--- ... Dista - -- - ----------- - --------- <br /> _�ce from. pun a.-ion . ..... 7 L.!,� <br /> No. of compartments------ --------capacity_�_ 4---- <br /> .... Size <br /> Y <br /> DisposalField: Distance from nearest well-----------------Distance-from foundation------------�'._Dis�fa�nce to nearest loline-----_------.-... <br /> Number of lines--------- --------------Length of each line----------- ------ -----------Width of french,----------------- <br /> I <br /> Type of filter material-------------- ----------Depth of filter material--_,_-_-.---- Total lengf h----------------------------------------------- <br /> - <br /> Seepage Pit: Distance'fo nearest well----------------------Distance from foundation-_-----------.--_-- Distance to. nearest lot line--_-----_-_.---_ <br /> ❑ <br /> ine_-------------- <br /> ElNumber of pits----------------------Lining material----------------------.Size: Diameter-----------------;_---Depth-,----------------------------- <br /> /-C1 esspool: Distance from nearest well-----------------Distance from foundation...........-----_-. Lining material---------- ----_-----__--.-----_-_---. <br /> 0 S•rze: D;ameter--------------------------------------Depth-------------- -------------------------------------Liquid Capacity__....:�----------------gals. <br /> Privy- Distance from nearest well---------------------------------------------- --Distance from nearest building------_------------------.-.---_---------. I <br /> ❑ <br /> uilding-:----M-------------------- ------------- <br /> El Distance to nearest lot li — il <br /> - ------- ------ <br /> i <br /> Remodeling and/or repairing idesc <br /> ----------------- <br /> (Jet- --------- <br /> -------------------MM------------......M------------------------------------------------------------------ -------------------------------------------------I---------------M------------1.------------- <br /> ---------------------------------------------------------------------------I---_----------------M-------------------------------------;------------------------------------------ ------------------------------ <br /> -----------M-M------------------------------------------------M------M-----------------------------------------I------------------------M------M--------------------I------------- -----------------;----------------------- <br /> I hereby certify that I have prepared this-application and that the work will be done in accordance with San Joaquin County: <br /> ordinan . a INS, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed)__ .----- --------------------------------------------- (Owner and/or Contractor) <br /> - - -----------------M---------------------- ------------- <br /> B A_Ni <br /> y:------------- --- --------�64NJIZL�--------- ----------- -------------------------m------m------------(Title)------ -------------------- <br /> �i etc., can be placed on reverse sid <br /> (Plot plan, showing size of location of system in relation to wells, buildings, <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY�� ---- -------- ----------------------------- ---------------------------------------- DATE_ --------------------- ----------------------- <br /> REVIEWEDBY------------- -------------- ------------------------------------------ ------------------------------------ DATE___� ------- <br /> BUILDING PERMIT IS. UED-..... ----------------------------------------------------------------------------------------------- DATE..__. F.-------.- <br /> --------- <br /> Alterations ----------------- <br /> ------------- <br /> and/or recommendations:----------------------............. --- --------_ - ---------------------------------------------M-------------I---------------7-------m------------------------ <br /> ---------------------------------------------------------------------------- --------- ---------------I----------M--------------------------------------------------------------------M----------------___--------------- <br /> ----------------I-------------­­------M------------------L-----------------------------------------­­-------------------------M-.......................... ------------M----------------------------------- <br /> ------------------------------------ -------- -------------•-•--------- ------------------------------------------------------ --- ----- ...... ------------------------------------ --- -----------------M.......... <br /> ---------------- -------------------------------------------------------------------------------- ------------ ---------------- ---------------------------------- ----------------------------------- ---------- -------- <br /> rBY:------- .......FINAL INSPECTION e(�/ /�--------------------------- Date- 4/4t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South Amerman Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> 14S446 ATWCOD <br />