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�. • # o ,tea APPLICATION FOR SANITATION PERMIT 1O (Complete in Duplicate) o � y 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 Ordinanco No. 549. JOB ADDRESS AND LOCATION_________-----I-s __1 ___-- ___ � --------------------------------------------- Address ------- - ---- Phone__o�"_b_,r�_�C_----- rOwner's Name----------------------------_----------------------�_QOM-.�-ir�q-------- -Ft�- - ----------------------------- Address------- ----J � L7eJv_F_-d£.R,_F---------------- ----------------------------------------- ------------------------- lr t+ �R1S _ �tT-Syr�C---- Phone g` Contractor's Name_______________________ �-- �'--- Installation will serve: Residence 19 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: [I Number of bedrooms [2 Number of baths 91 Lot _!---------------------- Water Supply: Public system �L Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 54 Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) W4 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---------------------------------------------------- C Privy: Distance from nearest well_______________________________________-_------Distance from nearest building------------------------------------------ Distance _ ---___________---_________.___-_-___. ❑ Distance to nearest lot line------------------------------------------------ Q Q if Seepage Pit: Distance to nearest well__N_QA _____Distance frr�000 undation ______ __'if"_Distanc� o nearest I line__ ___________ Number of pits_________________-Lining material__ 004*ize: Diameter______ _s _______.Depth____ _ _c ----------------- Number ____________ -- Dispo`sal field: Distance from nearest, well_______________.Distance from foundation ______________Distance to nearest lot line JDSI-I f er Number of lines-------------------------------- Length of eacli'li"ne== ----------- =.; _:Width..of trenc _ s ._ -- —. Type of filter material_________________________Depth of filter material_______________---__._ ..Remodeling and/or repairing (describe :---- ------------ ---------- --------------------------------------------------- ----- -- ---- ADD I k ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 yule and regulations o the San Joaquin Local Health District. t Contractor (Signed) Q_/1-�'r._- r7 r----------------------------------------------------- - ----- -rif (Title)---FES tn'1> i'JJQn---- By:------------4--- -(Piot plans, showing size of lot, location of system in elation to wells, buildings, etc., must be filed with this application}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --- DATE---�-------------------------------------------------- --------------------------------------------------------------------------------------- - REVIEWED BY QATE -------- ---- --- REVIEWED PERMIT ISSUED------------------ ----- DATE �C Alterations and/or recommendations--------------------- --------------------------------efrn------------------------------------------ ----------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------- ---------------------- ---------------------------------------------------+ ------------------------------------------------------------------- - ----------------------- - -------------------------------------------------------------------- -------------- �,. ---------------------------------- -- - PERMIT N� -------(gate A . ...-�---- --�-'�---�----- ISSUED------ �-l-�---5� � FINAL INSPECTION BY-- ----------------- - '�`,�'------------- Vl— Date------------ ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639