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APPLICATION FOR SANITATION PERMIT + 11 (Complete in Duplicate) l� f II ' 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. JOB ADDRESS AND LOCATION - J t ---------------- _ -------------------------------------------- Owner's Name--- Address )�_ Phone iF37 ---------- -- -------- Address -n------- _0 ----- ------------------------------------------------------------- ---- `k / , Contractor's Name � c.« s--�' u- ------------ -- Phone Installation will serve: Residence [Nr Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number.of living units: [j Number of bedrooms [I Number of baths [� Lot size---i—__ * __ ' ------,_p------------------------- Water Supply: Public system 4Community system ❑ Private ❑. Character of soil to a deptIi h of 3 feet: Sand ❑ Gravel [] Sandy Loam E] Clay Loam F-1Clay ElAdobe X Hardpan ❑ TYPE OF INSTALLATION;�AND SPECIFICATIONS: {� o seP •c tank or c p esspool permitted if public sewer is available within 200 feet.) _ Septic Tank: Distance i }i e from nearest well-"�___Distance from foundation___._ �__ Material___ -:----------------- No. --___-_ _____No, o 'compartments-----_2- _ "� Capacity C Size__S, -' -----Liquid depth-- .!�'� Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material-----------.--_ ❑ Size: Diameter---------------------- ---------------Depth--------------------------------------------------- Privy: Distance from nearest well-------------------------------- ------------Distance from nearest building ❑ Distance to nearest lot line_____________________________ Seeps a Pit: Distance to nearest well------ ----_------Distance from fo�y}��dation----- �J ___.Distance to nearest lot line_----f_d__ �- Number of pits-_--_f_____________Lining material__- _i' 'Size: Diameter__--- ._ --;Depth------to--�- --------------- M Number. from nearest well__— _Distance from foundation to nearest lot line---- Di Field: Distance of lines-_---------/__�_ __-_—. . _ !aJ_ _ -.-Length of each line------ -r______---Width of french-_ -S�_��--------------s osa Type of filter material_,_.i j.�.--.D.epthrof.filter Remodeling and/or xrepairing (describe)---------------------------------- ------------------------------------------------- - ------ --------------------- --------------------------------------------------------- ----------------------------------------------------------------------------•-------------------------------------------------------===---------------------- ------------ t--- --I herebcertif that- --- --- -f ---------------------------------------------------------------- -------------------------------------------------------------------------------------------•----------- y y have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and1ruLes and regulations of the San Joaquin Local Health District. - (Signed)--- 'Irk - � ----- - �` L3 i• /or Contractor -- -- ------------ � - r By: ----- ( ) (Plot plans, showing size of lot, location of system in relation to wells, buildings, efc., must be filed with this application). OR DEPARTMENT USE ONLY APPLICATION ACCEPTED,iBY ------------------------------------------------------------------------ DATE------------ - ---------- ----------- REVIEWED BY----------------------'�------------------ - -- ------------ DATE----- - ------------------------------ ---------------- - BUILDING PERMIT ISSUED' ---------------------------------------------------------------------- DATE Alterations and/or recommendations-------------------- --- ----------------- ----------------------------------------------------------------------------------------- k -------------------------------------- i --------------- --------------------------------- --------------'------------------------------------------------ -------------------- - ---- ------------ ---------------------- -----•------------------------------------------------ -- PERMIT No.-3.- _-C------- ISSUED----- -- ----+�-5-1,�-� (Date) FINAL INSPECTION BY------------- -- - .i Date---- SAN JOAQUIN LOCAL HEALTH DISTRICT I� 130 South American Street I Stockton, California ES--9-2M 9-50 W-1639 iI Jp�