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�l d 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. JOBADDRESS AND LOCATION--------3 ------------------------------------------------------------------------------------------------------ Owner's Name_..._R.a1ph__Ma __D3]7IIa1d------------------------------------------------------ --------------------------------------- Phone-----,.'82,27-------------- Address-----------------+ 415--Bad#---Park---at-►------------------------------------------------------------------------------------------------------------------------------------------- Contractor's Name---------S=i✓--•-----=---------------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Ej Apartment House ❑ Commercial [] Trailer Court ❑ Motel [❑ Other ❑ Number of living units: ❑ Number of bedrooms g] Number of baths aJ Lot size_____6OX115-------------------------------------- -- Water Supply: Public system ❑ Community system ® Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑l Clay Loam ® Clay ❑ Adobe ❑ Hardpan ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: a (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S/ Septic Tank: Distance from nearest well--5Q---ftDistance from . foundation__10---ft..Material---Reiv= d__- ---------------- No. of compartments _________2________ ___Capacity--�QQ___PalSize 'X9-'_______________- Liquid depth{9___ft_.___________- . Cesspool: material , Distance from nearest well_________________Distance from foundation___________________-Lining material_______________________________ ❑ Size: Diameter--------------------------------------Depth----------------------------- ---------------------- Privy: Distance from nearest well--------------------------------------------------Distance from nearest building.................................. ....... . k ❑ Distance to nearest lot line________________________________________________ Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line---------------- El Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth----------------------------_---- _Disposal Field: Distance.from nearest well---5Q---Ft.Distance from foundation_.10__-ft.e-Distance to nearest lot line___5__-ft. j Number of lines------------1j--------------------Length of each line��f� �j 9-d_,� Width of french___-___-a _/--.------------------ Type of filter materia --------Depth of filter material-------- -(0"______ Remodeling and/or repairing (describe)------------------------------------------ ---------- - ----------------------•----•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- hereby certify that I have prepared this appl' anonand that the work will be done in accordance with San Joaquin County ordinances, State la nd rules ri?IAAegulafions f e San Joaquin Local Health District. (Signed)---------- ------- ------ -- ----- ------- -- ----------------------------------------------(Owner and/or Contractor) By:---------Q n ------------------------------------------------ ------------------------------------ -----------------------(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 I APPLICATION ACCEPTED BY---- ------------------------------------------------------------------------ DATE-------fl_ - REVIEWEDBY--------------------------------w -f-7.............. ------------------------------------------------------------ DATE----- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- 1 -------------------------------------------------------•--•---------------------------------------------------------------------•-----------------------•---------------------------------------------------•--------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------- ---------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- PERMIT No.___1_6__Y-------- ISSUED-------- _5 ------(Date) FINAL INSPECTION BY:--------- -------------------------------------- Date---------------------f l r -------•------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California , ES-9-2M 9-50 W-1639