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APPLICATION FOR SANITATION PERMIT Y 2, (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 JOB ADDRESS AND LOCATION__cX2---- __ _Q____---------- __ ____ Owner's Name---- 'r te ---- --- { -------------=`------ -------------------- - ------------ Phone------------------------ Address-----r •-- - Contractor's Name------:-f 5 - C*'�" � ' Phone` (-- Jh Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Number of livingunits: ' Number of bedrooms Number"of bathsLot size<<__ � ,..�''-,�._,,�-per -Water Supply: Public system ❑ Community,system .❑ Privatex Character of soil to a depth of 3 feet: Sand ❑, Gravel E] Sandy Loam E]' Clay Loam L] Clay ❑ Adobe E]Hardpan 141- TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or cesspool permitted'if public sewer is available within 200 feet.) . .s r Septi Tank: Distance from.nearest well___�ja____--Distance from foundation____-0__ __.Material.... -------- p ��-------Capacity--- �a-------Size�`.�..:�- _•---- •. �. - Liquid depth---�r�--- -- No. of compartments--. _ Cesspool: Distance from nearest well-----_-----------Distance from foundation-------------------.Lining material_____:__ ______-------._____________.� ❑ Size: Diameter----------------------------------------Depth---------------------------------------------------- W Privy: Distance from nearest-well------_------------------------------------------Distance from nearest building------------------------------------------ , El Distance to nearest lot line___ ___________ _________________________________ r �� Seepage Pit: Distance to nearest w II ___ Pinin st came -. ndatp's#at�i" '�n�ar" of.Iin '__1t -_____Number of its_____ . ___ _-- material._,f�•t________''-=�iie. Dram®fie=---- --------._..D.�`Fh'�/' -- ----- Disposal Field: Distance from nearest well___6nLi--------Distance from foundation----1-4--- Distance to nearest lot line--- Number of lines___________ ___ Length of each line--------- Nidth offrench-------2-4-'o`___,__:___-_____ Type of filter material__1_ZL__-__e4h__Depth of filter material------ RemodRemodeling eling 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]-:.. '- • ' -- -�---- --------- -- ----------------- ---- ------ ------{�ar�sad/or Contractors BY� ----------------------------------------------------------(Title)--�� fix' • I r (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). ti FOR DEPARTMENT USE ONLY 1 k APPLICATION ACCEPTED BY----------------------- ------------------------------------------------ DATE------------ REVIEWED SY ---j=— ----------------------------------------------------------- DATE----------- ��1 ` / BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations:-------------------------------------------------------------------------------------------------------------------- -----------------------•---------------- ------ -•-----------------------------------------------••-- ------------------------------------------------------------------------------- --------------------------------------------------------------------------------------•-----------------------------••---------------------------------------•--------------- PERMIT No..-._IAL--------ISSUED--------1--- -_-- --l-----------(Date} FINAL INSPECTION BY:_________f----------- ---Vii_______________•- 7 -f - -------- ---------- kDate------------------------ � t SAN JOAQUIN LOCAL HEALTH DISTRICT M 130 South American Street Stockton, California ES-9-2M 9-50 W-1639 =1