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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) 3 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. ",4-) -. 7 JOB ADDRESS AND LOCATION__-_--- v�___r__�� _�__ _ ___ ;,-4 -- ------------------------------- _277Owner's Name... °�--__- _ *11, - Phone---------------------------- ----------I---------------------------------------- ------------------------------------------------------------ Address ----------- _ '� ---- Contractor's Name--------------, ------------------------- ------------------------------- Phone----------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mote€ ❑ Other ❑ Number of living units: [ Number of bedrooms E)�' Number of baths lj� Lot size------4,2--- - ----------------------- Wafer Supply: Public system ❑ Community system ❑ Private 1 74L Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 1� Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: C (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Z Septic Tank: Distance from nearest well------------------Distance from foundation--------------------Material----_-_-_-__-_-----_-----_-_--_----_----_--_-_-_. ❑ No. of compartments--------------------------Capacity-----------------------Size-----------------------------_Liquid depth-------------------------� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- -- 171❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- Privy: ------------------------------ -Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ M ---_-__----- .___--___---_-_-____--.❑ Distance to nearest lot line------------------------------------------------ Seepage Pit: Distance to nearest well----10Q______--Distance fro eundation n_. Distance to nearest lot line_-- ___ Number of pits-------- ------------ 'amaterialA&C_ i�i er--, - -- - Depth---------k-- .��.-__--_--� Disposal Field: Distance from nearest well------------------Distance from -___-___-___ -_-Distance to nearest lot—lino__-_.____ ,. ❑ Number of lines-----------------------------------Length of each line------------------------------- Type of filter material-------------------------Depth of filter material-----__----------_----- P� � 4 � Re odeling an /or .re airin (describe]:____-�___ _____'____± __ ____3 __��s flan. __ M4144_V_ ____ _ c� � - 'Y '- ------------------------ -A ----------------------- r .5 e -- ~ ►fir f •- `--'- J ' r r .e '# . -- - �'t� �� - �` --•-------------------------------- 1 ereby certify that I have prepared this application and that the work will be done accordance with San Joaquin County ordinances, State laws, and rules and: regulations of the San Joaquin Local Health District. (Signe d)---------- /�= '' � � _____� -�''1'"~! < -t.� (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 ' APPLICATION ACCEPTED BY DATE ..�, ---------------------------- -- ----- - ----------- REVIEWEDBY------------------------------------------------- --- ---- -------------------------------- DATE---; - f ;---------------------------- BUILDING PERMIT ISSUED----------------------------------- �- -------------------------------------------- DATE------ ---- -------------------------------------- Alterations and/or recommendations----------------------------------------------- --------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ ---------------------------------------------------*------• --------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - -----------------------------------------------------------------------------------------------------•------------------------------------------------- PERMIT ------ ISSUED....___. ----(Date) FINAL INSPECTION BY------------------ ---------o_ ---------------- Date-------------------- / r _------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639