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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health District 0for a permit to construct and install the work herein described. App Y �J ; C 77^-� .'3 This a plication is made in compliance with County Ordinance No. 549. 1�f�•P ' JCZZ &L A4 B ADDRESS AND L --- Phone-------------------------=---------- f Owners Name--------� --•--------•--- �--- - ---- - ..Address _ ------------------------------------------------------------------- f- -------- - ----- Contractor s Name_-..'l. �_�_ `_t_ 1i _ - - ------ Phone_2"�__nR� --••----- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � f Number of living units: -d Number of bedrooms 15, Number of baths � Lot size_r__,`�g ____. __f� ----"Al----- Water Supply: Public system ❑ Community system ❑ Private feet: Sand Gravel ❑ Sandy Loam ❑ 0ay Loam ❑ Clay ❑ Adobe Hardpan ti �' Character of soil to a depth of 3 f ❑ -- j TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public'sewer is available within 200 feet.) Septi Tank: Distance from nearest well--SA_- .___--Distance from foundation-_-_- ---�L ateriaa----- --------------- ---__-t------------ Se -_-_ . _. No. of compartments---------- ------------Capacity--_f1?4A-----Size/_ � __ .___.Liquid depth -----. Cesspool: Distance from nearest well_________________Distance from foundation__--_-- ---------.Lining materia------ y i ❑ Size: Diameter--------------------------------------Depth-------------------------------------------. -----• w t :� Distance from nearest well-------------------------------------------------Dista Distance to neance from nearest building------------_.__-------.------------- Privy:� , res}lot line- '--------------------------------------------- __TP_ ------------------- ----------------- ----- .� ,t. _- ,. 4 --'y r ' SeepageP�t 13istanceto nearest well ------------•Distance from foundation__. ---, Distance to nearest lot ine__.-------------- ------------ sf`b Numbe_r;of pits:: -•------=---Lining material---------------------- Size: Diameter Depth- r fes. Dispos�l Field: '�'=Dis#ance;frorri�nearest well____�_"_�-_-_`.Distance from foundation-=-14--"_......Distance.to nearest.lat,line_____ -._-____. Number of lines------------ ------------- --Length of each line- _ ®-'_�' `a- Width of trench----- i_y.'`-______--------- Type of filter of filter material----l------ -----:--_ 4 N --------------•------- Remodeling and/or repairing (describe):------------------- -•--------•------'------------------------------------------------ ---------------------- .: ---------------------------------- -------- ---------- --------------)---------------------------•-------------------------------=---------------------------------------------------------------------------------------------- .= =---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Gouniy ordinances, State laws, and rules,and regulations of the San Joaquin Local Health District. (Signed] - ' '--------------------------- -------------------------------------(Owner and/or Contractor) ----------------- ------------------- ----- Ti+le ------------------- (Plot plans, showing size of lot,.location of system in relation to wells, buildings, etc., must be filed with this application). -A - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. t = ---`�--------`------ --- DATE REVIEWEDBY---------------------------------- •-------- -- DATE--- -----------`--------' ----------------------------- BUILDING PERMIT ISSUED-------'-------=--------------'------------------------------------------------ --- ------------ DATE- -- ---------------------------- ------------------•-- Alterations and/or recommendations:----------------------------------------------------•------------------- -- ------------ ------------------------------------------------- --------- -----------------------------------------------------------------•--------------------•------------------------------------------------------- -------------------------------------------- � "�� (Date) FINAL INSPECTION BY: \1 -------------------- PERMIT No--------_--------------- ISSUED - -� ,� - • Date------------------------------------ ---------- ------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California i ES-9-2M 9=50 W=1639