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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) rr ?-rs`p31 Application is hereby made to the San Joaquin Local Health District for a permit to construct and ins+all the ork herein described. This.application is made in com fiance with ounty Ordinance No. 549. ��W 7`- Uf"�� / GR/NINIgL Z® (p7IU - w/"40� :_, ! JOB ADDRESS AN LOCATION___-- -- -Q-0-0_.-__---3M-,-_ _--- � ° Y -- - --------- -- -------------------------------- Owner's Name-.--- � � �- ---------—M__t` 1Q 5----------------------------------------- -- Phon --y4- Address � - Address-.--- ICY! WA 04-A _/-_601V - �rt��4. - �_z`�c� r'en G' ,�------------ - uu Contractor's Name------D(-- - L_.r1-lT- Sp_ S `-r,�1�� Q > - f------------- Phone----'7 Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms F1 Number of baths ❑ Lot size______________________________________--_ ------------------- Water Supply: Public system X Community system ❑ Private ❑ n Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeHardpan ❑ ^; TYPE TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) _nom Septic Tank: Distance from nearest well______________---Distance from foundation__,Y.........__.Material.CPA(.s__0/_?_;E-fes'/<._______ ` ® No. of compartments__7WQ---------Capacity_fOO ALSize-'- Tla--T& depth%�-0! Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-___-----______-___-_-------_ El 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-_ �Q________-.bistance to nearest lot line_Z--___-----_ Number of pits---OAfa-------Lining materialCplyC._S&OLSize. Diameter---3.3---- --3_3-----------.Dept h-��--,��--------- Disposal Field: Distance from nearest well-----------------.Distance.from foundation--------------------Distance-to-nearest lat-line-_._=_:---_--- ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench Type of filter material-------------------------Depth of filter material_--____----.___-_____ Remodeling and/or repairi (describe):____r tQ----------5-e--oalew.-z"----------------__1_Ysp----•----- �r-- ' --1 ------------- ---------- --------------------------- • - -f ----------. •----------- --- -- ------------------------------------------------------------------ -------- 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 a regulations of the San Joa uin Local Health District. (Signed)-------�_k----A- -------- ---- ---1"---R�_^-��<�- __I7- ---- ------ --------- -,9�-5 �C+ .-(Owner and or Contractor By: -------------z-`------------ a --------(Title)---- a --- ------ ---------- -------- - ----- (Plot plans, show g size of lot, location of system in relation to wells buildings, etc., must be file ith this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- --------------------- -AR-.__S-- DATE----- I-S-------------------------- - REVIEWED BY ----- - - - - -------------------------------- -------------------------------------- DATE ----------------------------------------- BUILDING PERMIT ISSUED---------------- ---- ------------------------- ------------------------------ DATE-------------------------- ---------------------- Alterations and/or recommenda+ions________________ ---------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------•------------------------------------------------------------------ -- - - - - -- -- PERMIT No----- --1-- ---- ISSUED---- -------(Date) FINAL INSPECTION----- - � "" -- - --. BY-- -----------��__�'t,-.,rral�..-.---------------- - Date-----------,--------------------------� - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-4639