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Z i 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. y JOB ADDRESS AND LOCATION __- 4 ------------------------------------------- --- ----------- ---------------Aq_,�t_A_-_-------- ------------------------Owner's Name----------- ------------------ ------- ---- -- -------------------------------- Phone ------ -------------- Q Address------------- - ---- � "�--`--'•_-•----- =----------------------------------------------------- i__ Contractor's Name--------------------- ----------- ------------------------------------------ Phone----------------------------------- C uP. Installation will serve: , Residence ❑ Apartment House Ol Commercial T ajler Cour} ❑ Motel E] Other i Number of living units:-'0 Number.of bedrooms ❑ Number of s Z- Lot size---- _ -------------------'_--.___ Water Supply: Public system Community system ❑ Private ❑ r j R Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [ Hardpan ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: T (No septic tank or cesspool permitted if public sewer is available within 200 feet.) #r.� Septic Tank: Distance from nearest wel17� _ __ -Distance fro foundation---4 /t�/� p Iv)aterral , I p P k - q p No, of com artmenfis____--_ Ca ac - ___Size_��________ - __ Li quid depth 'Cesspool: Distance from nearest well_________________Distance from,foundation-------------_------Lining material------------------------------------- El -------____-__ _____---____--___❑ Size:.Diameter--------------------------------------Depth------------1 =-------------------- �- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____._..__-_----------_________-_---_-:_ 1 ❑ Distance to nearest lot line___________________________________________---- P Seepage Pit: Distance to nearest well---------------------Distance from foundation--------------------Distance to nearest lot line----------------- Number ------------ -- Number of pits----------------------Lining material-----------------------SizeDiameter-----------------------.Depth--------------------------------- • -*.Disposal Field:=- Distance+from-nearest,well °7. Distance-frbrn`fou`ndatio-#�if_:�=__Distance'fo�near-e'st-lot"lih9--t - Number of lines-----l_____ Length of each line___/�,�------T-------Width of trench__,__��.��-_---____________ Type of filter material_�_1�� -----Depth of filter material_-'4_9-__'------ f -Remodeling and/or repairing (describe): '-------- --- ---------------- ------------------------- --------=------------------------------------------------------------------------- Or -- ------------------------------------------------------------- -------------------•----- - ------------------ - - - --- ---------------------------------------------------------------------------------------------------------------------------------------------=-----------------)--------------- 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. -. . l t = -------------------------------------------------------------------------- -------------(Owner and/or Cbntrac. tor)(Signed) =By -------•---------------------------------------=-------------- --------------------------------(Title)------------------ -------------------------------------------- (Piot 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--- -- -------------- ''3 ��° DATE' T k REVIEWED BY-------------------------- = r ------ ------------------------------- DATE- ,�� BUILDINGPERMIT ISSUED-------------------------- ----------------------------------------------------------------------- DATE------ ----- -------------------------------------- Alterationsand/or recommendations:--------------------------------------- ----------------------------------------------------------------------------------------------- ------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•- ---------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ PERMIT No._A_g1------------ ISSUED---- - ----------------(Date) FINAL INSPECTION BY:--_-__ ":r =--------------------------------- �+,�_- / yrs Date-----------------1 _ /----------------------------------- 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California R ES-9-2M 9-50 W4639 639