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I APPLICATION FOR SANITATION PERMIT (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. 10 0 JOB ADDRESS AAD LOATION a� fi '"I"�--- !.�' ---------- Owner's NaIf me---- ----------- C ------ -------------------------------------------- Ph ne-- - ------- Address-----------e-�--- `---------------------------------------` ,-s�J� --------------------��---------------------------------------------------------------------------------SCI- -C-----------`.e.'c Contractor's Name.....G...... �%� °� _______________ Phon _ Installation will serve: Residence Apartment House ❑ Commerciat. ❑ Trailer Court ❑ Motel ❑ Other„ ( Number of living units: E] Number of bedrooms Number of baths 0 Lot size-------------------------------------------------------------- Water Supply: Public system 19 Community system ❑ Private ❑ �} Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clayx Adobe Hardpan ❑'� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Tank: Distance from nearest well---- Distance from foundation-___../_Q_______.Material____________________________-------- Septic No. of compartments__...--___ L ____Capacity-----�600_f___Size_3?�✓rX_ ---------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: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- s ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------- _.____ Dis` zI Field: Distance from nearest well---- -----Distance from foundation__,lQ____-------Distance to nearest lot line___ Number of lines_______________ _---Length of each line----2 '-------=---Width of trench--------- -- � ... ✓✓✓ \\\ / ----------- ------------- Type of filter material_________________________Depth of filter material-------1,9N___.-___ Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------••------------------------------------------------------------------------- -------------------------------------------------------------------------------- -----------------------------------------------------•----------------------------------w -------•--------------------------------- ----------------- ---- -------------- -- ---------------------------------- --------------------------- -------------------------- -- -- I hereby certify that I have prepared this application and that the work will be don4sin in t with San Joaquin County ordinances, Sta lams; end rules and regulations of the San Joaquin Lodlal Health District. ed_ j --- ---_- (Owner and/or Contractor) / { i. .. (Sign -r By ---------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (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 APPLICATIONACCEPTED BY--------------------------- ------------------------------------------------------- DATE------------- --------------- REVIEWEDBY-------------------------------------------------------------------------------------------------------------------------- DATE---------------------------------•------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------------------- Alterationsand/or recommendations---------------------------------------------------------------------------------------------------------------------------- -----_--------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------••---•-••--------------------------------------------------------------------------------------------------------•----------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- --------•--•-•-- PERMIT No.__r _ ,�i ISSUED....�1_---------- _S_�---- (Date) FINAL INSPECTION BY:__ ---------------------------------- Date----- o-� --------------------•--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639