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FNt 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 describer This application is made in compliance with County Ordinance No. JOB ADDRESS AND LOCATION---10 " `''f ..__,... Owner's Name- �d _ - ---------------- --------------------------------------------------------- Phone f-------- �/ rf'�� r . Address----.2-9--1-'Z------ --0 44-1-71 --------------------------------- Contractor s Name__. Phone__ Installation will serve: Residence []_Apartment House [j Commercial 0 Trailer Court Motel . Other ❑ Number-"of living units: ' Number of bedrooms Number of baths Lot size___ r. _ � "---� r _ ' Water Supply: Public system' Community system❑ Privtn'� Character of-soil to a depth of 3 feet: Sand,❑ Gravel ❑ "Sandy Loam n Clay Loam ❑ Clay ❑ Adobe Hardpan 01. 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 foundation--------------------Material.----------------------------------------------_. ❑ No. of compartments-------------------------Capacity-----------------------Size--------------------------------Liquid depth--------- ------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material___________________----____________- 1 ❑ Size: Diameter---------------------------- -------Depth---------------------------------------------------- Privy: - ------ - - ----------------------------------- Privy: Distance from nearest well---------------------------------_r______________Distance from nearest building_-______________________________________. ❑ Distance to nearest lot line------------------------------------------------ Se p __________ _____________________________Seeps e Pit: Distance to nearest well_____p'_"_'"�`____Distance fromfou dation___rd0_t__ Distance to nearest lot line----- --r - ---- 't Number of pits----------/_________Lining material__43_/►--- ___maize: Diameter___.-C/,e_ ____.Depth_,2&d+_+�__:3Q_r_ Disposal Field: ;Distance from nearest well----------------- frorri,foi3ndt --------------------Distance to nearest lot'line____________..__- ❑ Number of lines-----------------------------------Length of each line-------- -------------------Width of trench----------------A'------------------ '` 11 ' Type of filter material___----____.______-_____Depth of filter material_______________________ z Remodeling and/or repairing (describe):----------------- � J-� �t'- �� f' - ------------- ------------------- ,. i _________________________________________________ ]� v R•-> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County, w ordinances. State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) � : r — ( id/or Contractor) IBy:------ - - --------- ---------------------------------------------------------------(Title) (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be fled with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------- ------------------------ --------------------------------------- DATE - ---------------------------------------- REVIEWEDBY---------------------------------------------------- ---------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED------------- --------------------------------------------------------------------------------------- DATE Alterations and/or recommendations:---------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------- -- ------------------------------------------------------------------------ - -------------------- ----------------------- --- ----------------------------------------------------------------- ------------------------- . w ----------•--------•--•------••---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- PERMIT No------e�--k_3-------- ISSUED---- ----------(Date) FINAL INSPECTION BY:-_�-W ------------------ Date----------f_ f` ' _ - M SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639