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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and insfall the work herein described. This application is made in compliance with County Ordinance No.549. JOB ADDRESS AND LOCATION----------------_-.(-_ _L7/—_6----------��__ �L-- ` —-------------------------------------------------------------------------- Owner's Name----------dl1_t--------]p `----------- �T r----------------------- ------ -------------------------------------------- Phone---r -� R.� ' ------ Address-------------- �� - -- ---------------------------------------------------------------------------------------------------- 'Contractor's.Name-------------IIS =IQ u 'M Q C� RP 14------------------------- ------ -------------------------------- Phone---C�-_"79-c'---7---------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size____________________________--____--___-____________________ V Water Supply: Public system ❑ Community system ❑ Private IX Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9 Hardpan TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----$' ---`-Distance from foundafion----L R_----_-.Material-__ ® No. of compartments------------ ------------Capacity------? a__------Size-___3.Y_.$_X_�- ---Liquid depth____-4/--------------- -- 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________________________________________________ r s r Seepage Pit: Distance to nearest we{I--------__ _i7_____Distance from foundation____ -------Distance to nearest lot line:____•2_0--- __ Number of pits----------Z---_____Lining material__'g_IZiKA---Size: Diameter_____-7.4_` -------Depth--_-___-ZQ-.°-------------- .Disposal Field: Distance from nearest well----ff-±G►______-Distance from foundation____!__0______--Distance to nearest lot line___ ® Number of lines----------------I-----------------Length of each line------450---------------Width of french---___Z---- _--01--------------- Type of filter material---t of filter material---------- Remodeling _____ ___Remodeling and/or repairing (describe):--------- ---------------------------------------------------------•-------------------.._.-_----------• ------------------------------------------- ---------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------ ----------------------------------------------------------------------------------------------------------------------a-------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, nd es and regulations of the San Joaquin Local Health District. (Signed)------ v I---------- ------- -'`AI-0"-------------------------------------------------------------------.-------------------------I er and/or Contractor) ___Title BY: { ) d `---------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be tiled with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY = ---------------------------------------------- - DAT ------ `' ----------------------- - REVIEWED BY-----------------------------------------I( y---------------- - - - DATE '` BUILDING PERMIT ISSUED--------------------------------------------------------------------------------•--------------------- DATE------------------------------- - - ------- -- ----------- Alterations and/or recommendations-------------------------------------------------------------------------------------------------------------------------------------- ----------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------- ------------------------------------------------------------------------------------------ -----------------------------------------------------------------------------------•------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- ---------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------/-----------•------------------------------ PERMIT No._/��------------ ISSUED__/I=,�-Q_--5�------------(Date) FINAL INSPECTION BY:----------��y----- ------ / ---------------------------- Date----------------1/--- �`-'- k re, SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50,W-1639 i