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APPLICATION FOR SANITATION PFRMIT - � r7 (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-AN D..-I.-GGA-FISN--------- - -------------------------------------------------- ------- Owner'sCame----- i - -------- -- - 1 ------------- ------------ J - ----------------- Phone ' --------------------- Address------------ Contractor's Name------- ---------------------------------------------- -----------------------------•--------------- Q-�.rf--r�-t':/___ - ------------ ------------------ -- - -- ----------------------------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ZI Number of bedroomsa 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 Clayk] Adobe❑ Hardpan ❑1.111_Z TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Disfance from nearest well 30�_ Distance from foundation_ ------Mat ateal-----------GOY — / - - No. of compartments______________�__-_____Ca Capacity---- - - --Size___-_---$--�Yr4 �-----Liquid depth----- ---'�-�---- ------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-__.______-__--___________---------_ ❑ Size: Diameter--------------------- ----------Depth---------------------- ----------------------------- 'Privy: Distance from nearest well-------------------------------------------------Distance from nearest building Distance to nearest lot line ---------------- ___________________-_______ Seepage Pit: Distanco to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_____________-_ ❑ .11 Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth- -_ t --------------------------- +_Dispos Field: Distance from nearest II____3 ------Distance from foundation-__2s,- -----_ Distance to nearest lot line___-. -�-___ . � Number of lines-----------�---- -- --Length of each line-----------_3��---------Width of french--------,�-/-------------------- Type of filter material__ .__ -_ IGC_Depth of filter material________ r-/ Remodeling and/or repairing (describe):_______________________ ---------------------- - --------------------------------------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinanes. State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)__'K,,__ -------� --- - --------- --------------- --_--_--(Owner and/or Contractor) (Plot plans, showing size of lot, location of system in relation to wells, bu -------------------------------------------------------------- )-------------------------------------------------- --- ildings, etc., must be filed with this application). FOR -DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ REVIEWED BY _ - ---------------------------------------------------------------- DATE----------- - - --------- - -- -- ---- -------------------- --------- ------------------------------- DATE----- ----------- BUILDING PERMIT ISSUED_________________ ------------------ DATE ---------- ------------------------------ -- -- --------------------- Alterations and/or recommendations____________________________ - 4_1 ----------�-------- ---------f'�-�� '`--�-- ------- _ _ - � -----------------_-----------•_-------------------- -----•--- PERMIT No.__l-211-..----- ISSUED-___ _713 -- _ (Date) FINAL INSPECTION :__ Date--------------- { � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street i E5-9--2M 9-50 W-1639 Stockton, California ,� r