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APPLICATION FOR -SANITATION PERMIT ! (Complete in Duplicate) f t a l o9-100 --r3 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. /h JOB ADDRESS AND LOCATION------W7 . - --- - . s 0 -- ----0_ ---------------------------------- -- Owner's Name------------- C_-,. herry---------------------------- - - Phone--------A---~r l Address----------------------------------- ------<i-0"-T-A ._4-To-_K-t� --------------•----/---------------------------------------------------------- Contractor's Name--------- -��. i.�� r. xri------------------ ------- ------------------------- ----------------------------------------- Phone--N----'-,09-------------- Installation will serve: Residence © Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [:1 Number of living units: ❑ Number of bedroomsE Number of baths Q Lot size--- i52-------------------------------- Water Supply: Public system EX Community system ❑ Private ❑ , Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑—Clay Loam ❑ Clay ❑ Adobe ® 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___-_D----_____Distance from foundation_"___1' -------Material---- r-e- ------------ - ---- No. of compartments--------2---------------Capacity----ECO-----------Size--- --------------Liquid depth----4---_-.-------^----"_-. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---___ _-_--.------_---_"________-_-_. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------- Privy: ------------=--------------- -Privy: Distance from nearest well------------------------------------------------Distance from nearest building - t ❑ Distance to nearest lot line------------------------------------------------ Seepage ____"_"-_"----------------------------------- -Seepage Pit: Distance to nearest well-----0----------------Distance from foundation___._�0---------Distapce to nearest lot line.____'----- WNumber of pits-------Z------------Lining material__Br2_!'k------Size: Diamete r _f__.Depth--__Ia _----__-_ Disposal Field: Distance from nearest well______-----Distance from foundation____,"___ ---Distance to nearest lot line-----/ Number of lines-------------/__-_---_---__"__ Length of each line---._----_ E/ � � - 9 �-�--��------W�dth of french- -`�'�----------------'-- Type of filter material_"_�_/�_ _Q _ __Depth of filter material---___!9-"------_" Remodeling and/or repairing (describe)---------------------- rgtr . H-^-- ---------------------------------------------------------------------------------------------------------- ------------------------------------------------------------•---------------------------------------------------------------- - ------------- . ---------------------------- ----------------------------------------------------------------- -------------------------------------------------------------------"--•----------------------------- ----------•--------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S aaws, and-rules and r ulations of the San Joaquin Local Health District. .i (Signed)- ` � v '--------------------------------------------------------------(Owner and/or Contractor) : k By: --------------------------------------------------------(Title)-------�d��r - (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-- - REVIEWED BY----------------------------------- - - -�� -- DATE-----------4L-- BUILDING PERMIT ISSUED------------------��--- -----•-•-------------------------------------------------------------- DATE------------ Alterations and/or recommendations:-----------------•---"--------------------------------------------------------------- -------•-------- r -------------------------------------------•-------------------- --------------------------------------------------------------------------------------------------------•---------------------------------------- �1 ------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------- ------------------------:------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------;Z;------------------------------------------------------ •---------------------------------------- ------------------------------------------------ ------------ PERMIT No------- ISSUED-----\X --------- _ ---------((Date) FINAL INSPECTION BY:----1-/--�------,�-- ---------- !� f Date--------------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ! Stockton, California 9 - r