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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) i 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. rte_ •. JOB ADDRESS AND LOCATfON----- ` � -- 'L --- Cif \ �.- �+ Owner's Name (/D-IP ----------------------- ------------ ------------------------------------- Address -------------------------------•-------------------------------------------------------------f---------------- ----------------------------------------------------- Contractor's Name----------------------------------•-•-----4_��J/f' Phone------------------------------------ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: EA Number of bedrooms 2- Number of baths Q1 Lot size_________ ___ ___________________________________ Water Supply: Public system ❑ Community system ❑ Private Er-, Character of soil to a depth of 3 feet: Sand E] Gravel L] Sandy Loam El Clay Loam ❑ Clay E] Adobe [ Hardpan'[ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Y Septic Tank: Distance from nearest well_______________ Dist nce from foundation=__-____- --_-_ Material `.= '' ❑ No. of compartments----------------- -------Capacity-----------------------Size---------------- ---------------Liquid depth------------------------ I Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material_________________-_---_______-____� .El Size: Diameter--------------------------------------Depth--------------------------------------------------- Privy: Distance from nearest well------------------------------------_____________Distance from nearest building ❑ Distance to nearest lot line------------------------------------------------ Seepage ---- ------------------------------------ ----- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line___-_____________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-----------------------------t ,Dispas I Field: Distance from nearest well------------------Distance from foundation--------_ __________Distance to nearest,lot line------`_______-_ _ ' r Number of lines__________________ ___________ _Length of each line________��______y,__Width of trench_ Type of filter material_ Aepth of filter material________1 ____._ _ ._.•. _> v Remodeling and/or repairing (describe):-------------------------------------------------------------------------------- - -------------------------------------------.--------------------------,-^ r. _ . „ - Gc -------- Fin--cfi ------------------------------------------••--------------------------- --------------•------------------------------------------------------------------------------------------------(/ •------------------------- ---------------- 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) -----------------------------------------------------------------------------------------{Owner and/or Contractor) (Plotplans, showing size of lot, location of`s. em-in-relation to wells, buildings;'etc., must be filed-with-this application].- 1 16 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- ,---%�- y� --------------------._------- DATE----------- �,---- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE-------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE---------------------------------------------------- Alterations and/or recommendations:---------------------------------------------------------------------------------------- - ------------------------�-�-----------F-----------r------------.a_--- - -='----_---- / -Y--------- ----------------------- ------------------------------------------------------------------------- t�c hllt, ;[ r fj!- �, a °` ¢ _ �_ ----------------------------------- ----------- ------------------------------------------------------------------------------------------------------ - l ------•--------- �' PERMIT l' -- - -_---------_ ISSUED--_- ----__ --------(Date) FINAL INSPECTION BY---------- - --- ---------------------------------- _>7 - -Date------------------9":777.: -- ------ (� r SAN JOAQUIN LOCAL HEALTHDIST !CT 130 South American Street f Stockton, California E$-9-2M 9-50 W-1639 _ �J