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APPLICATION FOR SANITATION PERMIT L <br /> 4-2A 0 (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described:- <br /> This application is made in compliance with County Or finance No. 549. <br /> JOB ADDRESS AND LOC TIO �Z A-------- ------------ -----------4L1;9;!-_-....'------------------•-•--------------------------------------------------- <br /> Owner's Name----------- ------..10 --- A------- ------------ --------------------------------------------- Phone-----3-Q---f t- ------ <br /> Address ------I----------------------------------------------------------------------------- ------ <br /> Contractor's Name---- f.�.1 k _ M/------------------- ------- ------ -------------------------------------------- Phonew2.1fo-'t--------- <br /> Installation will serve: Residence Apartgent House ❑ Commercial 0 Trailer Court 0 Motel 0 Other <br /> Number of living units: Z Number of bedrooms :L Number of baths V Lot size.... Q._._ ____.Z� r_______________ <br /> Water Supply: Public system ❑ Community system Q Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material--------------------____-_------_____._-___-_---- <br /> QNo. of compartments--------------------------Capacity----------------------Size-------•------------------------Liquid depth-------------------------- <br /> Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material_______-____•----_____--___--_--__-.-. <br /> ❑ Size: Diameter----•-----------------------------Depth------------------------------------------......... <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____--_.-_-_______----___-______---__-•;__ <br /> ❑ Distance to nearest lot line--------------•_______--____•---____-_--:_..____ <br /> -Seepage Pit: Distance to nearest well_____________________Distance from foundation--------------------Distance to nearest lot line------------------ <br /> El Number of pits----------------------Lining material_------ ------- ---Size: Diameter-------------.---------.Depth----------------.---------------. <br /> r / <br /> ,Dispo al Field: Distance from nearest well-._-�- -__.Distance from foundation .................Distance to nearest lot li �__ .__._ <br /> �-�' ' <br /> Number of lines............../_------------__..._Length of each line_______�v___ -----Width of trench_..._ _____._..__..__________. <br /> Type of filter material__I�_ _4_Gt -Depth of filter material---.___1f--------- <br /> Remodeling and/or repairing (describe):-------------------------( _-_;•_ <br /> ------ ------- / t <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------•----------------•--------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify t*ru <br /> pared this application and that the work will be.done in accordance with San Joaquin County <br /> ordinances, State 1 "regu tions of the San Joaquin Local Health District. <br /> (Signed)----------- ---• ---- ---------------------------------------- ------------- ---- ner and/or Contractor) <br /> By:--------------------- --------------------------------------------------------------------------------------(Title)---- -- - - t----------------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings,etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------•--------------------------------- DATE-------- y� <br /> REVIEWEDBY---------------------------------------------------------------------------------------------------------------------------- DATE........................................................... <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------------------- <br /> Alterations and/or recommendations--=---------------------------------------------------------------------•------------------------------•----------•--------. - <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---- <br /> ----------------------------------------------------------------•-----------------------------------------------------------------------------•--------•----------------------------------------------------------------•-•-- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------- <br /> � <br /> - 1..„. // --------- --- <br /> ---`----------- ---------- - ------- <br /> PERMIT No.4�/-6_-___ ISSUED........... .....Y.'�_3_ i_(Date) FINAL INSPECTION BY:..... )__L_ 4 --_•-._.............. <br /> Date. -� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />