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APPLICATION FOR SANITATION PERMIT ✓C (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. JOB ADDRESS AND LOCATION---------/ 0---------- 6-A -'S�-------- -----`T�-.--------------------------------------------------------------------- Owner's Name-------� --- -A--I- P- -------------_- --- ---------' ----- -~ ------------------------------------------------------------- Phone----, �f_�_�------------- Address A t T" �� ---------------------------------------------------- Contractor's Name----- ---R--r— Phone 1?0if Installation will serve: Residence 1K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 5l. Number of living units: '� [ZNumber of bedrooms Number of baths [7 Lot size________04-440- ________-_______ __________,__ # Water Supply: Public system Community system El Private El r,.� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,& Hardpan 1 i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feetiI) Septic Tank: Distance from nearest well_________________Distance from foundation---------l---------.Material___________________.______________:_____________- ❑ No. of compartments--------------------------Capacity-----------------------Size.......------------------------Liquid depth-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation---------_----------Lining material_____________________________________- ❑ Size: Diameter----------------------------- -------Depth---------------------------------------------------- Privy: ;-------------------------------------------------- Priv Distance from nearest well______________________________ Distance from nearest building Y = 9 ❑ Distance to nearest lot line______________________________--y____________ Seepa e Pit: Distance to nearest welL_______-4`07'_Distance from�foundation___ __ $_.Distance to nearest lot line_�_g_______ Number of pits--------I------------Lining material__ __R__lC. __Size: Diameter_____a_�_________.Depth_____ __0_______________ I 1pispasal Field: Drstance from nearest well------------------Distance from foundation---------------------Distance to nearest lot line_________________ ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench-------_---------_ _-- Type of filter material_________________________Depth of filter material------------------------ . I Remodeling and/or repairing (describe)_________________ ---------------------------------------------2< _- -" ---------At Ixx`,� �- ---- �x _+---------- ----------------------------------------------------=----------------------------------------------------------------------------------------------------------------7-------- - ---------------------------------- ------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 les and- regulations of the San Joaquin Local Health District. (Sign ed)..--- � --- '�"`�`-- �`�s '-----------------------------------------------------------------------------------(Owner and/or Contractor) By:------------- --------------------------------------------------------------------------------------------------------------- Title ------- - (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 '�~ ----------------------- DATE t rff APPLICATION ACCEPTED BY-------- _____ __________ : REVIEWED BY------------------------------------ ---------------�- ----------------------------------------------------- DATE------------------------------------------------ , - ---- - BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE----------------------------- - Alterationsand/or recommendations:---------------------------------------------------------------------------------------------------------•-------------•--------------------------•----------- -i ------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1 ------------------------------------- --------------------------------------•-•-••--------------------- --• -- - PERMIT No.--3--6__7---------- ISSUED---------------------- ---------- (Date) FINAL INSPECTION BY:-.-- y ------ ------ Idate ------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amdridan Street Stockton, California ES-9-2M 9-50 W=1639