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Co r APPLICATION FOR -SANITATION PERMIT Q s (Complete in Duplicate) I alM �. ► h 'e GSL . G 0 t [r(any~' d� /r?x) qo--16 4 [ Application is hereby made to the San Joaquin Local Health District for a permit to co rust and install the work herein described. This application is made in compliance with County Ordinance No. 549. C ' JOB ADDRESS AND LOCATION---- ------ � �L�&' A Owner's Name----- -------------- -------- ----- -- --- ---- - ----�--- �- -- -- ------------------------------- - - -- Phone------------------------------------ � r ------- Address 1 f5` J �` �- -- :.�,----._ ---------------------- Phone----- `=�"=='------------ � Contractor's Name--------------�--------------•------•----------------------- ---------•--- ------------ ------------ ---- ---------- Installation will serve: Residence og"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: T Number of bedrooms [4 Number of baths [� Lot size_______ ". -..." ---fJ�r� t Water Supply: Public system ❑ Community system ❑ Private Dr Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 5K Clay_❑ Adobe ❑ Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) y, Septic Tank: ' Distance from ,nearest well__,. _ ____.Distance� from foundation---,�42:_______-Material----- _ ----- No. of compartments--------�Y Capacity -- Size Liquid depth_ p tY Cesspool: 3 Distance from-nearest well-----------------Distance from foundation--------------------Lining material_______-_---_____________---________. ❑ ----------------------------- Priv Distance from" ' Size: Diameter nearest well________-" Dept -------------""" Distance;from nearest building_._'__-___-_______________-_________ p ❑ Distance to nearest lot line---------------------------------------------- ; E Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_,_.____-_-____. fro s-------------- --=Lining material--_ Size Diameter Depth ❑ .,. Number of pit / Disposal Field: Distance m,°nearest well___ = D,istance�from foundatibDistance to_nearest lot IEne __ -- .,�-rLen +h,of each line ' �(Vidtth of ench --------'1.r�- r} . ( Number of lines_____ ____ g ` Type of filter material__ `�z___�:,? __ epth of filter material--- Remodeling and/or repairing de ` scribe . � ----------------------------------------!=s-"-l----• . _-b- �. - ------ --------------------- - pp _ -. , ---- -------- - -------------- --- ---- herebcertif that Ihave - - - q ----------- -------------------- ------------------- y y prepared this application and that the work will be done m accordance with:San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. g ' (Signed)-. .: I-ems "lr ---------- �,._ {Owner and/or Contractor) Title -------- Y• -------------------------------------------( } (Plot plans, showing size of.lot, location of system in relation to wells, buildings, etc., musVbe filed with this application). FOR DEPARTMENT USE ONLY ------ --- ------------------- - p DATE------ '-------- --I--------------- REV REVIEWED BY ACCEPTED BY--- ----------------------------- DATE----------------------------------------------------------- - -------------- ---------------------------------------------------------- - .; DATE---------------------------------------------------- BUILDING° PERMIT ISSUED-------:,"------------------------------__--------------- - l Alterations nd r reco men tions:________________---------;`: ----------------- r r Q --------- ---------- - - ---ef. ---- ---- ----- 1 _ -------------------------------------------- _ ====-------------- --------------------------�='--- ---------- �� ;:...,� PERMIT No.___-- _ ------(Dame) _..FINAL INSPECTION SY: - � �`� � •-� � .` -------- �--�---- ISSUED----�-Q--�--�-. -.-- Date_ e— � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639