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APPLICATION FOR SANITATION PERMIT7 (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. b.5,_3 per{ ----------------------- ,JOB ADDRESS AND LOCATION_._ �� fOG�� S+ �E�� - �w�'�r------------------ Owner's Name------- ----------------- Phone---777777------------- Address-------E =5------ --------------- -------------------------------------------------------------------------------------------------------------- Contractor's Name----------------- ------------------------------------- -- --------------------------------- I ----------------------- Phone----------- �----------------. Installation will serve: Residence Apartment House ❑ Commercial ❑ - Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ® Number of bedrooms ZE Number of baths 0 Lot size______ ___ -------0_Z--r--_______________ Water Supply: Public system Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ 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_____1 Q_g7__Distance from foundation-----1_D+_______.Material_______C-0—/V -_____________ e No, of compartments----------71-—--------Capacity---._80_Q_-Q_____--Size---4Y X-.--A -----Liquid depth--------ly-------------- Cesspool: ----- _-_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________________________________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-____-_-____--__. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- Disposal ------------------------__----- Disposal Field: Distance from nearest well___-T'A___'___.Distance from foundation----,(_d_'______.Distance to nearest lot line____,l 4 Number of lines________In_____________________Length of each line-------44_o_l-____--------Width of french______ _Y_"___________,___ Type of filter material__:__t' _�_ ______Depth of filter material______ -_`__---_ _ ----------------------------------------------------------- . Remodeling and/or repairing {descri'oe)_----------___��1eS�________--__._____ ___.•----------•------------__-_- [�) ---------------------••---------------•-----------------------------------------------•-----------------------•--------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------- hereby certify that I have prepared this application and fhatithe work will be done in accordance with San Joaquin County ordinances, State laws, and rules and' regula+i ns of the San Joaquin Loc I Health District. (Signed)- "r }----- `_ :. ' _- - ------------------------------------------- ------------(Owner and/or Contractor) (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 �' - s T. REVIEWED BY------------------------ ------------------------------------------------------------ ---------- DATE---- -- ------------ ---------------------------- ------------------------------ ' BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---=-------------------------------------------------------- Alterations and/or recommendations: - ------------------------•------------- ! ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- f PERMIT NoA0_,3-_;7 ISSUED-- 1--.__(Date) FINAL INSPECTION BY:__ ��. ----------------- Date------- JOAQUIN LOCAL HEALTH DISTRICT k 130 South American Street Stockton, California FS-9-2M 9-50 W=1639