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} A 3 APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) l 1 - 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 compliance with County Ordinance No. 54�9.��1 JOB ADDRESS AND LOCATION______________ _�------ - ------- ;--------- Z -------------------------- 1 ----- ----------- F Owner's Name---------�.!4�-- 1=� � ----- ----------------------------------- Phone-----��-�--- - -�----- - 1 r Address----------- --� 1=� ''''' eX ---------------------------------------------------------------------------- Contractor's ----------------------- - -+ - Phone---------------------------------- Contractor s Name - -------------- -- ----------------------------------------------- -------------- ------ Installation will serve: Residenc A tRa a Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: '� Number of bedrooms ,Number of baths `7 Lot size______- --- ----2- - --------F= Water Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑. Gravel ❑ Sandy Loam ❑ Clay Loam [ Clay ❑ Adobe ❑ Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: -- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 1 Se tic Tank: Distance from nearest well _ ___Distance from foundation__J_ Material_____ . --�-------------- p / � ---- -i No. of compartments------ ----�-------Capacity--- rtd-ledation ize_ _2--f _ -- L __Liquid depth__:_-------------- - -- 4 Cesspool: Distance from nearest well----------------- from f __- _____,______.L'sning material____--_ ._.____-_____-_.____------. € ❑ Size: Diameter------- ------Depth------------------------------- ------------------ ¢ Privy: Distance from nearest well--------------------------------------------------Distance from nearest building--------------------_____________- ❑. Distance to nearest lot line----------- --------------------------------- f Seepage Pit: Distance to nearest well___a_-b-------Distance from foundation---I_ ________Distance to nearest lot lin%.41_ Number of pits------- -----------Lining material-----------------------Size: Diameter_____�6__!__/____-__.Depth___ ---____�r_ Disposalfoundation t Field: Distance from nearest well-________________.Distance from foundation__-_--______-_--___Distance to nearest lot line______-___--_-_-_ Number of lines---------------------- ------Length of each line---------------------------- Width of trench----------------------------------- Type of filter material--------------------------Depth of filter material----------------------- -- Remodeling an repairing (describe): ► 1 :-------- ----------------- -`' _____.._______ ____ _____ _ _____________________________________________________________________________________-.F ______________»-________________________________________________ ___________ ____,---_______ u F ----------------------------------- ----- ----- - --------------- ------------`_---------------------------------------------------------------------------------------------------------------------------------------------- ----- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. G ^ -----------------(Owner and/or Contracto Si ned - ---- -'_---�-�-�--�``-f`�---- ; ---------- ( 9 } By: - 5 .. .-..; Title (Plot pStti� skowing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). Y FOR DEPARTMENT USE ONLY APPLICATION ACCEPITED BY------ - DATE-------- tt - REVIEWED BY--------------a------------------------- ----W4---- --------------------- - --------------------------- DATE------s - ------r ------------ BUILDING --BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE--------------------------------------------------------- Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------•----=------------------------------------------- ------------- .--------•--------.- ----------------------------------------- ♦ k ________ ---------------________ ___ ______________________ 000. GAJ f ^� ---------- - ---------- ---- - ------------------ T�r A? . -- �------. T T� = Q��r v F ------------------------ P1 RMIT No. ISSUED - (Date) FINAL INSPECTION BY: = ----- --- ----------------- Date----------------- -�• � �------------------------------- ter, SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California FS-9-2M 9-50 W-1639 V,, 9