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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__•pG ------------------- Phone--- ---------- Owner's - Z- ' Owner s Name__ ---- ------ ------ I - --------- ^ a Address _.�� t 4_r7""- C. ..----"------------------------------------- 4" --------- Phone_ =- Fil a- --- A c Contractor's Name--- ---�{ , --- - --- ------�---- .`'.;„i - Motel Other ❑ Commercial Trailer Court ❑ ❑ Installation will serve: Residence [� Apartment House ❑ ❑ ----------------- d Number of living units: [ Number of bedrooms Number of baths [ Lot size____ "-64_--- - 4 Publics stem Community system E:1Private 'V Water Supply: Y ❑ sClay Adobe[� Hardpan ❑� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [:1 Clay Loam[] y ❑ r 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__//Q---__Distance from foundation------L--_------- Material----&----------"-_--- --------------- [�"'0------Size__Lr4---X-3--L-------Liquid depth__t �_.- ------. No. of compartments_________�..�---------Capacity_____ -- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material_----_-""______-____-_____ ❑ Size: Diameter--------------------------------------Dept ---------------- -------- --------- --------- - - ______Distance from nearest building------------------------------------------ Privy: Distance from nearest well--------------------------------____:__ ❑ Distance to nearest lot line------------------------------------------------ r r Seepage Pi}: Distance to nearest well----- from f ndation____-"- Distance to nearest lot lin _ .------- Seepage _ - , Size: Diameter_gyp Depth2.4_ ----------------- <:Number of pits-------/-------------Lining material_ -AV Number --- ---------- - Z� Disposal Field: Distance from nearest well_.�-"__''_--_.Distance from foundation__-/IJ--_-"___--Distance to nearest lot line-- --------- Number of lines__________ Length of each line_____--___- _-� Width of trench-_-_--Z- {_.!----"--"""--"- gg �' 7,�/! ___ epth of filter material-------fr�___------- Type of filter material_1.,�_ D Remodeling and/or repairing (descr'ssbe)----------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- ----------------- --------------- - -------- ---- ---- - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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. d or Contractor) Signed f!! �----------------` --- -------_� -`--------------------------------------------------------- -------- -- -- ( � ) -- �,� (Title] - -- ------------ "�"`--'---------------- -- - - (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). R FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE-----4--�---- i'1t" v� - ----------------------- ------------------------------ BUILDING "-------- --------- ----- DATE--- --- -----------•------------- "------------ ---------- REVIEWEDBY-_---------------------------------------------------------------- - ----------- DATE BUILDING PERMIT ISSUED------ --------------------- Alterations and/or recommen-d--a--t--i-o--n--s-:- ----------------------------- "--------- "-------- ---------- ----------- ----------" ----------------------------------------------------------------------- ------ ------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------- ----------- - -- ---------- ---------------- --------------------------------------------------------------------------------- - ----------------- -------{Date FINAL INSPECTION BY:-----------E/V ------------------ PERMIT No."_ --y---- ISSUED----- _--f-- --� �1____,� - ----------- -------- --------------- ate----------------- ------- --- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 WwI639