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U 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. / 4 JOB ADDRESS A LOC TION l!_/ �-`-- --------------=------------------------------------------------------ Owner's Nam//e.. ��i ------ Phone............................... Address lit . -.. -c.�•,p_!... --- ----•- Contractor's Name t;f" '' Q�� 4 -------------------------------------------------- Phone.. d .. Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: . Number of bedrooms Number of baths [ f Lot size---- ------------ 1 Water Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe . Hardpan ❑ 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-_----__-______-____--_-____---•.______-____-___- Il No. of compartments-_----------------------Capacity-----------------------Size--------------------------------Liquid depth-----_-------------------- Cesspool: Distance from nearest well.................Distance from foundation---.___.............Lining material-------------------------------------- Size: _--•-_____•_•_--- _--___-__-__-__.Size: Diameter--------------------------------------Depth------------ ----------------------------------------- Privy: ----------' -Privy: Distance from nearest well----------------------_______________•__..•______Distance from nearest building________.-._._-____.___..-___- .......... ❑ Distance to nearest lot line-_•-.--•________________________________________ i Seepage Pit: Distance to nearest well_.___--1�------__Distance from f ndation...-_�a_--•--.Distance to nearest lot line �b of pits......../...........Lining material� ------------ Number Size: Diameter----ffJ Depth_ _ - Disposal Field: Distance from nearest well___/9.1...Distance from foundation---_�."—_.Distance to nearest lot line.../V_�-..- Number of lines___._.________ Length of each line......... -•a ..........Width of trench....�--�[.�!________________ y-„ j--- Type of filter material_l j____. ..(...Depth of filter material......�r-------- Remodelingand/or repairing (describe):-----------------------------------------------------------------------------------------------------------.............................................. -------•--•---------•---•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------- ---------------------------------------------------------I-------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,USta% llaw , and s and regulati s of the San Joaquin Local Health District. (Signed)------ - ---- ------ --------- -- ---�".-.- ---------------------------------------------- ;l0wwwwor�d/or Contractor) By: ----------- title)_ (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). ,AF R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.......... ------------------------------------------••--- WE------- REVIEWED BY...................................... ---- --- ------------------------------------------------_- ---_---.- DATE --- �....�� --..L..�r_._� BUILDING PERMIT' ISSUED = ........................---------------------------------------------- DATE.-------------------------------------�------------ ----- Alterations and/or re mmendations_________________________ .........I-_-_-._._____--- _ .tail .: - r '-� ' ------------- ------------------------------------------------------------------------------------ --------•---- ...................................�' 6 -----•-----•------------------------- ----------------- --- ----------_- . .. . . PERMIT No—e2-4:-.7_.....-_ ISSUED---- ._ . .......(Date) FINAL INSPECTION BY:......... f -------------------------- Date------ -------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W4639