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A, 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 appl'c tion i a in compliance with County Ordinanc' 0. 549. le 7;40xE2xNVLC0 T --- --------- ---------------------------------------------------------------------- CA JQN--- Owner's Name----Celr--------- - - - --------- ------------------------------------------------------------------------------ Phone------------------------------- Address-----1_/-02__/ hone------------------------------- Address_..____-1_/_02/------ -- - - - ----- --- ---- ---- ---------------------------------------------------------------------------------------------------------------A� '9 ------------------------ ---- -------- Contractor's Name_ --------------------- -------------- Phone__7 Installation will serve: Residence Apartment House [I Commercial Ej Trailer Court [-]- Motel El Other E] Number of living units: Number of baths 3 11 A 1 V Number of bedrooms V t Lot size___ 0-- ---------------------------- Water Supply: Public system E] Commuonity system El Private Character of soil to a depth of.3 feet: Sand E] Gravel F] Sandy Loam E] Clay Loam El Clay El Adobe A Hardpan El 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-------Z M ateria ------r------------- No. of compartments_-______j2-----------Capacity---- -------Size-5-4--- -7------Liquid depth---472------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_______-__-_________________________. ' ❑ aterial------------------------------------- El Size: Diameter--------------------------------------Depth--------------------------------------- 'Privy: ------Depth---------------------------------------'Privy: Distance from nearest well-------------------------------------------------Distance from nearest building______-.__________________________--___ - ❑ uilding---------------------------------------- - El Distance to nearest lot line________________________________________________ f clation------ .".Distance to nearest lot iine---Af 110------ Seepe Pit: Distance to nearest well......go---- Distance from I Number of pits-------J-----------Lining material--- ize: Diameter------------------- ----------------- Disposal Field: Distance from nearest Distance from foundation-_--_1-6 Distance to nearest lot line__k ____f____ t e-� Number 5 __/---- Number of lines----------- Length of each line____--;7-0 -,VV-.Width of trench-------:2 --------------- Depth of filter material -------- Type of filter material___ _, Depth 'Remodeling and/or repairing (describe)------------------L---------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------I------------------------------------ --------------------------------------------------------------------------------------------------- -------------------------------------------------------------------I—----------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------I---------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and' regulations of the San Joaquin Local Health District. 5i ned A------ -------------------------------------------------------- ------ Q*aemaad or Contractor) - �=----------------- By:----- -- -- -------------------- ------- -----------------------------------------------ffitle)_e7 5�� (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-------- --W--- ---- L_ ----- DATE______ . REVIEWED BY---------------------------- ----------------------------------- DATE------------------ - ----- ------------- . BUILDING --------------------------- - PERMITISSUED------------------------------------------------------------- --------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:----------------------------------------------- ---------------------------------------------------------------------------I----------------------11----------- --------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------1•--------------------- --------------------------------------- ------------------------------------ ----------------------- PERMIT -------------(Date) FINAL INSPECTION BY-------- ------------------------ Date---------------------- ------f 1 ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639