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APPLICATION FOR SANITATION PERMIT 4"Do (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. 5,49. JOB ADDRESS AND-JOCATION. ,�� 4ezm -- Z�- -------------------------------------------------------------- Owner's Name........ ------- _ _ - -- --,' PhoneM--------------------------------- --- --------- --------------------------------------------- Address_-_ .. .- --'"�!------------ Contractor's Name._. _s}, . - ,�,.e ��-/ Ph ._.. ' _Q �.l� one.. �`. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑(�Motel Q Other ❑ g y r of baths It Lot size_.-._rQ�__ Number of living units: Number of bedrooms Number Water Supply: Publics stem �3eeh Community system ❑ Private IX Character of soil to a depth of 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.) i Septic Tank: Distance from nearest well-----------------Distance from foundation-_"-"--_"--__"-.....Material ______________ ❑ No. of compartments--------------------------Capacity- ----------Size--------------------------------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________ --------- ------------ Seepae Pit: Distance to nearest ell---- QDistance rpm fo ndation__---- ' __Distance to nearest lot line.- Number of pits....... -----------Lining m ._ l � --Size: Diameter---•x767-•---- Depth--"-- .2-0--------- -•--- DispoI Field: Distance from nearest Jp�(' we/ll------------------Distance from foundation.................... Distance to nearest lot line. Number ...�._._._._._._._._._._._. Length line•-._..� '____.Widthof trench........ _- Depth of filter material.__..Type of filter material.._ 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 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed).- ..---• --- --------- ��_ C `' , .r ---------------------------- or Con tractor) ... BYEr �.�......� -----------------------.................(Title)- 0 plans,lowing size o lot, location of system in relation to wells, buildings, etc., must be filed with this application FOR DEPARTMENT USE ONLY rr'''' APPLICATION ACCEPTED BY.... /--------------------------- Y....9/-------------------------- ------ DATE_._Z..... - .......--REVIEWED BY................................'1_6_4 BY"-------------------------------'1-�4 ----------------------------------------------------------------------- DATE----- '--�---��-�------...----------...- BUILDING PERMIT ISSUED--------------------------------------------------------------- ------ DATE ---------------------- Alterations and/or recommendations: - -- -•-............................................................ -------------- -------•--------•------------------------- ----------------- --- PERMIT No.....�5---------•_ ISSUED-------- �lS v -- -----� (Date) FINAL INSPECTION BY:__...__-_U Date--------- . �_~-� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W=1639 Stockton, California