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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) 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 ee}}with Count Ordinance o. 5t9. JOB ADDRESS AND LOCATION Z__ --- ----- -- --------- --------- ----------------------•---------------- Owner's Name_--___- � } _-_-_ Phone_____®-- ----- Address------ «. -- --------- ---------------------------------------------------------------------------------------------------------- Contractor's Name ----- --- _L-- -------- - Phone Installation will serve: Residence V Ap rfm House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ [Number of living units: umber of bedrooms A Number of baths UO Lot size___8�___?..-��_�__________________________ Water Supply: Public system Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feel] Septic ank: Distance from nearest well "________Distance from f undation____�__ __ �r__.Materi I____________ 1r xax No. of compartmeats----•------- ---------Capacity___ _ ---__Size_ --(t---------- Liquid depth------ --_-------- Cesspool: Distance from nearest well_________________Distance from foundation-------------------- material-------------------------------------- 0 Size: Diameter........--------------------------•-Depth---------------------------------------------------- I Privy: Distance from nearest well---------___-------------------------------------Distance from nearest building---------I______________________________- ❑ Distance to nearest lot line------------------------------------------------ 1� Seepage Pit: Distance to nearest well----------------------Distance from foundation----_!__'____.Distance to nearest lot line_-Ia'_►_------- w ❑ Nu' ber of pits----------------------Lining material_--------_-------------Size: Diameter----..:.-it.--------------Depth'---_---------------------------- Dispas l Field: Distance from nearest well-�� ' Distance from foundation / 0 _ Distance to nearest I line------- _____ Nu tuber of lines----------- ___�iJ____________Length of each line--------------- It of trench_#____ __:____________.-____._ Type of filter materia . __ _` epth of filter .. material___-_______________ Remodeling and/or.repairing describ - , - kfl if --------- -------------------------- v - --------------------------------------------------------------------------------------- ---- ------------------------ ----------- ----- ... ---------------------------------------------------------------------:----------- ----------------------------------- --- x 5.. ..- - ��------ I hereby certify that.I have prepared this applicationkand that the work will be done in accordance with San Joaquin County ordinances, State laws,;and rules and regulations ofihe.S-an(Joaquin Local Health District. �J� :Si ned. ` �' �--- -- - ----------------------------(Owner and/or Contractor) • 9 r Y---------------------------------------------------------------------------. -; -------------------------------------------------(Title) =--------------------------------- t (Plot plans, sho#ing size of lot, location of system in relation to well's;buildings, et .,-Au3t be filed with this applk ation). FOR DE ARTMENT USE ONLY APPLICATION)ACCEPTED,BY +` _-__•_, 1 ., ------------------------------- DATE } ------------------------ REVIEWED BY ` ---------- ".DATE_. ------------ BUILDING PERMIT ISSUED!-------------------------------t�---"-.'...---- -+----- -- -------------------------------------)-(DATE--------------------------I-------- y Alterations and/or recommendations----------------} --------- "- -- --------- ------------- ------------------- -•---------------•---------------- - _7 7 !_ ..x.¢ _ll, , .—_.,-r __ , it ---------------------------------------------------------------- ---------------------------------- ------------- -------------------------------------- ---------------------------------------------------------------•-•----------__.--------------- ----------•--------------t---- ---------------------------------=� --------------------------------------------------------- i---------------------------------- - --: = __ -- _ _ =' -- - - PERMIT No[F--_ J__--__-- ISSUED-------_-- --3 -----(Date) FINAL INSPECTION BY--------------v _ --�------:----------------------------- Date--------------------- --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639