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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) �9 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. qtr JOB ADDRESS AND LOCATIO .�� - 4 ' r�-� . ------- Owner's Name--� --- ------------ Address------ --------•--Address------ rral0---- -- • Contractor's Name-------------- - - - --------------------------------------------- ----- -------------------------------------- Phone , ---------------- Installation will serve: Residence Apartment House E] Commercial F1 Trailer Court E] Motel ❑ Other ❑ Number of living units: 'V1 Number of bedrooms umber of baths 0 Lot size ��_-_�._l_�---------------- Water Supply: Public system ❑ Community system ❑ Private Character'of soil.to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [I Clay ❑ Adobe [r' Hardpan TYPE OF INSTALLATION AND SPECIFICATIONS: -�- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) j Septic Tank: Distance from nearest well----SO----Distance from foundation______f 9_t-.Material____--� 7,rrNlh__ - C< No. of compartments-----_---fes----------Capacity----9-Q-0------size---- x--�--1�_.�._Liquid depth-------_ ------------ 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-----------------------Size: Diameter----------------------_.Depth-------------------------------- . . .Disposal_Field;4 ,Distance from.near.est,well___064_____-Distance-from-foundation __�� Distance.-to-nearest--lot-1' Number of lines--------- - 1 ---___-_- Length of each line-------------� __--Wid hrof trench_------�__------ f-- Type of filte material___ ___De th of filter mat riaL____L-8 _ .. j- Re odel ng a� /or repairing (describe).: -- -- ------------------------------ ---------------------------------------------------------•------------------------------------------------------------------------------------•------------------- --------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County r ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. s (Signed)---------------- ---- --------------------(Owner and/or Contractor) Plo+ plans, showing size of lot location of system in relation to wells, g Y• --------(Title)---------------------------------------------------- --------- -----------------`-=----------- -------------- P g � buildings, etc., must be filed with this application). —FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE---- f_ REVIEWED BY �` �r'tW-P DATE - `'_ - * ,,.�y ---------- BUILDING PERMIT ISSUED - ------- ---------------------------- DATE Alterations and/or recommendations:--.`-------------- ------- - _,---- '"--, -------------_41-------------- - - - -{ - . ---------------- kn ----C1 -- iii- :=: --------------------=-- -------------------------------_---------------------____-------___-------_____------------------------------- -----___ ------------ __-.------_________- P____..-.__ ._..___ PERMITNo-------------------------- ISSUED------------------------------------------ f ------------- - ------(Dated FINAL INSPECTION BY:--•---------.-------------------- ------------- x Date------------- 4J SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 4-50 W-1639 f