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APPLI� ATION FOR SANITATION PERMIT l0 (Complete in Duplicate) A `lication s hereby made oot San Joaquin Local Health District for a permit to construct and inst I the work herein described. pp Y q This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATIOj----/Q-f__j_3----�r,4J-----U------- A !°C�c _,�u • �1 > 1`/"� Owner's Name-------4-4 � �-#I- h7 � ��f� � Phone--(-q,-� �� --------------------------- a...-- � r,b „ "� ��_------------------------------------------------- ------------- ------------------- Address =- Contractor's Name------...� �-- _' =S^` - --------------- Phone--------------- : ► 1 ------------------------------------------------ - 1 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 4 Number of living units: •Ul Number of bedrooms 2 Number of baths [4 Lot size--------- ___________________ 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- Distance from foundat'on-- __1_Q'4_____-Material_____a" + lALL�_s�-a,+f_______________ artments___________ No. of compartments �nt---------Capacity-----10�Q Size----=�f--�-�-Uig-�---.Liquid depth-------4------------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__------.----_.____________________.__ ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- `Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---'.------------------------------------- El Distance to nearest lot line________________________________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_____________--_ ❑ Number of pits----------------------Lining material----------------------- Diameter------------------------Depth------_-_------------------------ Disposal Field: Distance from nearest well___:�_Q--__.Distance from foundation----U_._.......Distance to nearest of line_________ Number of lines-------------'Z. ______-1_--Length of each line--------4-Q--------------Width of french----------�--------------------- # Type of filter materiaV,6--�__6c_!C---Depth of filter material--------- S�!_____ -Remodeling and/or repairing (describe):--------------/J e"o-----'.N_C -/1- f` ------------------------------------------------•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. (Signed)----- --------------------- --------------[Owns and/or Contractor} iD (Title)--- - - ------------------------- (Plot plans, showing size of lot, lotion of system in relation to wells, buildings, etc., must be fled with this application). FOR DEPARTMENT USE ONLY ---------- -- ---------------------------------------- DATE------ - APPLICATION ACCEPTED BY----------W-__-V-- � � ��/- ------------- REVIEWEDBY---------------------------------------------------------------------------------------- --- ----- - ------------------------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- k Alterations and/or recommendations----------------------------------------------------------------------------------------------------------------------------- ----- ------------------------ -------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------•------------------------ ------------------------------------------ ---------------------------------------------------------------- -------------------------------------- --------- - ------------------------------------------------------ PERMIT No.-Wel--0tJ_____-- ISSUED------- --/ 7e--------(Date) FINAL INSPECTION BY:--------------------�------P& _____.___.______-- Date-------------------------�a ��- ` ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street , Stockton, California FS-9-2M 9-50 W 1639