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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. JOB ADDRESS AND LOCATION-----------1Q3-5-!4a- Brafikdxa-y---------------------------------------------------------------------------- Owner's Name-_--_ Ax AQQt----------------------------------------------------------------------------------------------------------- Phone_--SOa. Address-------•--10.3-5---5-�---Broadmay--------------"--------------------------------------------------------------------------------------------------------------------------•--------------- Contractor's -----------------------------------------------------------I------ Phone--- _:955------------- Installation will serve: Residence Q Apartment House ❑ Commercial ❑ Trailer Court ❑ Mofel ❑ Other ❑ ,. Number of living units: '® Number of bedrooms [2 Number of baths P Lot size--_--50__X_228--------•------------ ------------- Wafer ____________________ ___Water Supply: Public system [�; Community system ❑ Private ❑ n \ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ® Hardpan ❑O, TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if public ewer 's av ilab w'thin 20 f et. well used $ Irrigation only Septic Tank: Distance from nearest well_-2-O_-01 --Distance 'rom foundation___ ____________Material_-_camant--____-_----_---- t L] No. of compartments-------------- ----------Capacity-----__QQ----------Size----91-X3-1-X5-1......Liquid depth----41,__ , Cesspool: Distance from nearest well--X=---Distance from foundation-AEE------- Lining maferialYL4AjYff4jX------------- Size: - Size: Diameter--------------------------------------Depth-------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------- El Distance to nearest lot line--------------------------------- Seepage Pit: Disfance to nearest well--------______________Distance from foundation--------------------Distance to nearest lot line----------------- El existtndlumber of pits---------------------Lining material------------------------Size: Diameter-----------------------.Depth--------_------------------------ ._..=,_I7isposal.Eield: ,Distance from nearest:well=_______ __—Dis#once from4oundafion________ --------Distance-fo-nearest lot line_' -__-- ❑ exist inglumber of lines------1--------------------------Length of each line____40---__-_-_-----_-__-Width of french----App_,.---2'....... Type of filter material-------------------------Depth of filter material-_--____-----____:--_ Remodeling and/or repairing (describe):----___-___-rep-a-IrIng--------------NOTE-to----the--oxxxer---Xx'_r---�.�---R-•---{iook--------- --------- —Wants---t-Q--b-uy---4---neer----8-e t_i-Q__t.ank-with---proper_- 0-0=er-tio-n__�a----ld---1��..�x'a �� e i -the---iald__ceazpoal---o-sued_-•1n--only-------------------------------------------------------•----------------------------------•-----------------------------------•-------- ----------------------------------------------- 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. De ,t-a--Sep C---Z --Se-ra-lo-e--- ------------------'-------------------------------------------(Owner and/ Contractor) i (Signed) By:--------- --- ------------------------------------------------------------------ -----(Title)-------- 0wnpr- MZ---'------------ d------------ (Plot plans, showings e o o , location of system in relation to wells, buildings, etc„ must be filed with this application). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------- ------------------------------------------ -- DATE--- + ` REVIEWEDBY----------------------------------------------------- ---- -------------------------------------------------------------- DATE-----/1A--- G BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations: i -- - r-------- --------------•------------------- ----- ---- ------• - - - ------------- ---------•--------------- ---- --------------------------------- ----- ---- ------------- ------------- -- :----- -• -•-------------------------------- PERMIT N,.---13--q--------- ISSUED---Y/!---I-q-21-`-'-t ----------(Date) FINAL INSPECTION BY------ ----- ---------------- - --------- ------ ----------- Date----------- -•- --------- - ----•--- SAN JOAQUIN LOCAL HEALTH DISTRICT 134 South American Street Stockton, California ES-9-2M 9-50 W-1639