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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______________ ------------------ T c /v T A(Owners Name------ � ' Address ------ ��• -�' 4 - Phone ' DTo c ontractor's Name -- --------- --- -- -- -- - ---- Installation will serve: Residence N. Apartment--House- --❑-- Commercial* -- --------- - Phone___ _ ....... ❑ Trailer Court ❑ Motel E]Phone E] Number of living units: ® Number of bedrooms J] Number of baths m Lot size--------/p l__ Water Supply: Public system 0 Community system ❑ Private ❑ Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ® Clay Loam ❑ Clay TYPE OF INSTALLATION AND SPECIFICATIONS: El Adobe El Hardpan ❑ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----- � ---Distance from foundation_-_---_ IJ No. of compartments_---_ -___ '� r Material___-_____ ' L?-uJ �s f? 11---------- Capadtyl��r- � Size_,��`f � Cesspool: Distance from earest ell-- ----Liquid depth____-y__----__--_- __--,- Distance fr foundation--------------------Lining material-------_----_____-------------------- --❑ Size; Diameter--------- ---------- ----------Depth-------------------- ----------------------------- Privy; Distance from e rest wel _____________ _ ❑ Distance to nearest lot li �. " Distance from nearest building-______,--"_-- " eepage Pit: Distance to nearest well____________ ___ Di nce from foundation-------------------- ❑ Number of pits--___-----"-__.__-_---Lining material_____________ Distance to nearest lot line------_-_____-__ ---------Size. Diameter------------------------Depth_-------------------------------- Disposal Field: Distance from nearest well--__�raQDistance from foundation-_f___'1_ Number of lines______________4.-___ 0-------Distance to nearest lot line___-_____ --------- Length of each line--- -- ` �-,5--°Width of trench------- ---------------------- ------------ Remodeling - Type of filter material-ifs A0C-Zt"Depth of filter material-_--"�--b---__ " Remodeling 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, Sfafe laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--------------------- L---=1-`��--__-'---------'_�;.•---=---'--•�-' �--- - (�,�� L� fF __ -----.--------------`-`-------------__--------_----------- "--------------- ---------------------- -------- ner arrdyor Contractor] BY (Plot plans, showing size of lot, location of system in relation to wells, buildings, efc., must.be.filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ------------------------------------------------- -> REVIEWED BY �EATE BUILDING PERMIT iSStJED---------------------- - -� ---- ------ ------------- ------- ----- DATE ----------------------------------- ----------- ------------------------------------------- Alterationsr' - DATE- and recommen ations:-__*____________ __ _ _______--__-_ = l!� -- per ----------- `-' - - R -r_x --------- - - --- � �� . �,,�.�_ �,t-----�---�. --- ------------------- mac , --------------------- -- ---------------------------------- -------- ; ------------=----- - ---- --f - ----------------------------------------- --------- ------------------------------------ PERMIT No------------------------- ISSUED-----------------------------------------(Date) FINAL INSPECTION BY: -------------- - --------------------- Date ---------------- --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W-1639 Stockton, California