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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Application is he y This application is made in compliance with County Ordinance No. 549. ------- 0---H--- � 1- -----------------------------------------•-------•----------- JOB ADDRESS AND CATION_________- �.5 -- _ a�� ' `� ---------------------------- Phone_ ----- Owner's Name----------------- Q[°F(7"d'IV 11 p L°-t - Q _1_r^ - --r"------- --------------- Address----------------- f CPhone--- F� Q pz) c Cf :___ _ 'J Contractor's Name__ _/_-----1 _ n. Other [jInstallation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court El Motel ❑ Number of living units: 0 Number.of-bedrooms'X Number of baths JZ Lot size -x- Private ❑ Water Supply: Public system .� Community system ❑ Cla Loam ❑ Clay ❑ Adobe Hardpan ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Y N TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or cesspool permitted if public sewer is-available within 200 feet.) Septic Tank- Distance from nearest well-----------------Distance from foundatioize___.___.____-- Material Liquid depth___________________ ❑ No. of compartments--------------------------Capacity---------------------- :. Cesspool: Distance from nearest well-----------------Distance from foundation.______ _ ___ _______-.Lining material-------------------------------------- 'Depth---------------------------------------------------- ❑ Size: Diameter--------------------------------- i Distance from nearest building ------------------- Privy: Distance from nearest well-------------------------------- 11 ------------------------------❑ Distance to nearest lot line------------------------------------------------- ----------------------------------- - ------` r ' +� � _ ------.Distatf e to nearest lot line Qisance to nearest well--- from foundation__- Seepage Pit: lC _Size: Dimeter____ �______ ___.Depth---_.;7-1 -f---Q----------------- - Number of pits---0&&-----Lining material___ Disposal Field: Distance from nearest well------------------Dis a}h of each lune a}ion---------_-- =--Distance tf} rg�hest lot line----------------- ❑ 'Number of,lines________________________ g Type of filter material------------------------- of filter material________-_______-_____ r ' ------------------- - ---------------------------------------- -- Remodeling and/or repairing (describe):_______ __ , _� �r--l /� ---- rsr� -' - 6 - --4'c` T ----------------------------------------------------- ------------------ ----------------------------------------------- --------- ------------------------------------------------------ p-_p I hereby certifythat I have prepnd ared this ons application the San Joaquin the work w cal Heallth®Di}r,�{n accordance with San Joaquin County ordinances, State laws, and �} C' Own �a / ontrac#or) (Signed)JI f X f �� i , _441L ------------------------------(Title) � J� -- - g (Plot plans, showing size of lot, location of system in r lation to wells, buildin s, etc., must be file ith #his application). FOR DEPARTMENT USE ONLY DATE__ --------------------------------- APPLICATION ACCEPTED BY________ --- - - - DATE_____ -- ---------------------- r ----------------------- - ---------------------------------------- DATE ----------------- BUILDINGPERMIT ISSUED------------------------------------------------------------•---------------------- -------------------- -------------------------------- --------------------------- Ai+era+ions and/or recommendations;--------------------------- ------------------ - __-__ ------------------------ ---------------------------------- ---------------------------------------- --------------------- ---------------------------------------------------------••----------------------------- J --------------------------- -- - ' -------(Date) FINAL INSPECTION BY------- -- ---------- ------------------------------------ PERMIT No----- --------- f ,� ---------------------- - ---------- ------------ --- Date-------------------------�---�-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 WA 639