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42,11 APPLICATION FOR SANITATION PERMIT 41 (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 jOrdinance No. 549. JOB ADDRESS AND LOC TION---- O4.-_L__ C�______- -- -- --- ------------------------------------------------------------------------------- Owner's Name-- _ ��-- - Phone - - - ----- ---- Address .2 �� --------- ----------- ------------------------------------------------------------------------------------ ---------- - -- --ems, e-�-,------------------------ Contractor's Name-- �_ *- ----------------------------------------------------------------------- Phone__1`---1-_4.41-2 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: IP Number of bedrooms Number of baths I Lot size__-- Water Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe OK Hardpan ❑ 4 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 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______________________-______________ Seepage Pit: Distance to nearest well s _Distance pIn foyndation--_3oir__-_._.Distance to nearest lot line-_j Number of pits______ ------------Lining material_-_(___ _-__+ __-__-Size: Diameter----- ---VVV .IK.�i Depth---- Distance epth ? ----- ------------- Disposal Field: Distance from nearest well------xr___ .Distance from foundation---- '-----Distance to nearest lot line---J _�_____ t Number of lines__ ___ *r_-_____Length of each line-__--- 2�5l� :- _ Width of trench__ A/---Type of filter material-1 ----an 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)-------Pt A! � I Ant -----_ /or Contractor) By:------ : s (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 APPLICATION ACCEPTED BY-------------------- V/f-- ------------------------------------------------------------- DATE 3 V �p —------------------------ REVIEWEDBY---------------------------------------------------------- BUILDING PERMIT ISSUED--------------------------------- ------------------------------------- DATE------------------------------------- Alterations and/or recommendations______ - -------- ---------------------------------------------------- ------ ------- - ---------------------------------------------------------- PERMIT No. _ _, ------ ISSUED__-_____-_ _-E -S_ (Date) FINAL INSPECTION BY:-------- __ ----- - ------------------------------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W=1639 Stockton, California