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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 with County Ordinance No. 549. JOB ADDRESS AAcof LOCATION ---------° -------------- d v --------- -------------------------------------------------------------------------- Owner's Name------ ---- ------------- Address----------------------------------------- ------------Address---------------------------------------- - -� 3Y -------------------------------- ----------------- -- ----------------------------------------------------------------------------------------------- Contractor's Name--------------------------------------------- -Lam-.----------------- - -=--------------- Phone---------------------- --------------------------------------- -- - ----------- Installation will serve: Residence [Z Apartment House 0 Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms © Number of baths m Lot size-----------!KO-----X____.50_d------------------ ' Water Supply: Public system ❑ Community system,❑ Private rof Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam X Clay ❑ Adobe ❑ Hardpan ❑ v TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet.) Septic Tank: Distance from nearest well______32__ ____ Distance from foundation-----/�_____-_.Material ________*d-w&d-------------------- s No. of compartments___________�,----------Capacity----_---5-:�0----Size---- ��-��___--Liquid depth---s.5 _.__--_____________ Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material-------------------------------------- El Size: Diameter--------------------------------------Depth---------------------------------------------------- Priv : Distance from nearest well___________________ ________Distance from nearest buildingI ❑ Distance to nearest.lot line________________________________________________ n Seepage Pit: Distance to nearest well----------------------Distance from foundation---r __.Distance to nearest lot line----ZW___ ❑ Number of pits----------------------Lining material-------_---------------Size: Diameter------------------------Depth------`----------_------_-__----- i i Disposal Field: Distance from nearest well__J_0------Distance from foundation_.____;2Q____-_Distance to nearest lot line____�� g a� /----Width of trench------------------ ------ . a �� [� Number of lines---------------- L ____Length of each line____________ Type of filter mate rial____�, __'Cvl�f----Depth of filter material----------2y-------_ Remodeling and/or repairing (describe):----------------------------------- -w-j------VVSr;47kAlt-'•?-`-� ---- ----------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------•---------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------..-----__----- ------------ ----------- ----- ---------------------------------------------------------------•---------------------------------------------------------------------------------------------- I hereby certify t at I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la , and s and' regulaf ns�F he an Joaquin ocal Health District. �. (Signed)---------- -- - - --------- -- ------ ---------------------- -- ---- -----''-------------------------------------------------(Owner and/or Contractor) ! BY:----------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------------ -------------------------- (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------- -f REVIEWED BY----------------------- ----------------------V-------- --------------•------------------------ DATE-------- /-- - --------------------- BUILDING PERMIT ISSUED--------- ------------------------------------------------- --------------------------------------- DATE---------- ----- Alterations and/or recommendations--------------------------------------------------- -----------------------------•-----------------•-•--------------••---------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- -------------------------------------------------------------------------- ---------------------------------------------------------- ------------------------------------------------------------------------------------=---------------------•------------------------------------------------------=----------------------------------------------------------- -----------------------------------------------•--- = ----- PERMIT N //---- ---- --------- ISSUED �'��J- f Y /�" -- --` 6�' __--(Date) FINAL INSPECTION BY:-•----------•----------ff---------------- --- - ----------=-- Date �7---- i-------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639