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APPLICATION FOR SANITATION PERMIT v� 1 (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 with County Ordinance No. 549. ®,pI �-moi JOBADDRESS AND LOCATION------------------------------------------------------- ------------------------------ ------------------------------------------------------------------- W�r's Name [-- �R_f------_�,.>._i�11----63114V�r --------- Phone------------------------------------ Address Q,- '� -C--------�^+' �A'-4-4----- ----------�� "------0 —--y------- -------- Contractor's Name----------------------- l =--------------------------------------------- Pho.ne_�'7 --------- {' -�� Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size____________________________________________________________ Water Supply: Public system ❑ Community system ❑ Private ❑ K '� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑�! v TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if px tower is available within 200 feet.) Septic Tank: Distance from nearest well___ ___Distance fro foundation______l7_,____'I�lateri�l____!�►__ /_'________--- -�__�_____. f No. of compartments-------------A:------Capacity------ -----Size----,. --2<r_ ----Liquid depth----- ----- ---------. s Cesspool: Distance'from nearest well-----------------Distance from foundation-----------------------.Lining.material-------,------------------- ;_ ❑ Size: Diameter--------------------------------------Depth-------.--------------------------------------------- Privy: Distance from nearest we41-------------------------------------------------Distance from nearest building----.--------------------------_ ❑ Distance to nearest lotrline_______________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line______ ------ Number of pits---------------- Lining material-----------------------Size: Diameter-----------------------.Depth--------- ------------------- Disposal Field: Distance from nearest well__ __.Distance from foundation____ /__4_---____.Distance to nearest lot line-r_________: _�_I__ Number of lines----------------/----------------Length of each line-------- Width of french----- Type of filter material_-1%y__{+tA—Depth of filter material_____ _ ________ rremodeling and/or repairing (describe):-------- ---------------- --------------------------------------------------------------------------------------------------------------------------- ---------------- , - ------- --- - --- ---�' ' --------------- 1 ------------------ ----------------------------------------- -------------- ----------------------------------------- I . > � I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la tan trules d regulatiJoaquin Local Health District., ------------- ---------------------------------------------------------{Owner and/or Contractor)(Signed � � - By:------------------------------------------------------------------------------------------------------------------------------------(Title)----------- i - --------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___ _ DATE--- ` - REVIEWED BY------------------------------- ----------------- DATE--- r_;�,,�-------------------------::------------` .. 4:� R. BUILDING PERMIT ISSUED DATE �-------------- Alterationsand/or recommendations----------------------------------------------------------------------------------------------------=------------ --------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------- ----------------------------------- ---------------------------------------------------------------------------------- -----:- �a_______ ISSUED_____l4_"_5'��5 ----____{pate] FINAL INSPECTION BY � `'___________ PERMIT No----- _�__� - --- . ti. Date-------- ---- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street JL Stockton, California ES-9-2M 9-50 W-I6.39`