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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_____ '.� ______ I'_ --- - ------------------------- Owner's Name_ �vv -------------- Phone ,:l Q Address '. Contractor's Name________________________________ ----------------------- ------- ----------------------------------------- -- - -- -- ------------------------- Phone --------------------- - - Installation will serve: Residence ® S Apartment House I] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: [21 Number of bedrooms Z Number of baths ❑ Lot size- Wafer Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ® Hardpan F1 TYPE OF INSTALLATION AND SPECIFICATIONS: �1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest_well__/Y �---- 1 Distance from foundation___ D-�_____--Materjal_Liquid dep-th-/------�_C! "� ® No. of compartments---------�------------Capacity---g�_ f1 lSize �x_ - _-- f ----- f - ---- -- -------- - Cesspool: Distance from nearest well_______ ________Distance from foundation--------------------Lining material--------------------------- I ❑ Size: Diameter --7�'----Depth--------------- :Privy: Distance from nearest well____________________________________-_________-Distance from nearest building - ❑ Distance to nearest lot line________________________________ --------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- to nearest lot line----------------- :VF Number of pits----;=�iiiil - Lining material-----------------------Size: Diameter-------- -----.Depth--------------- ----- .Disposal Field: Distance from nearest well- _Qt:__.Distance from _� foundation____ 1`�---------Distance to nearest lot line___ S -_�_--__ f�I Number of lines__________ _ Length of each line___ _ __________________Len _ r �r g 7---'r-- Width of french ._ ------------------ Type of filter material-------------------------Depth of filter material____________________ _ 'Remodeling and/or repairing (describe)-------------_---------------------------------------------------------------------- J h ----- --------------------------------------------------------- --------- --------------------------------- ---------------------------------------------------------------------------------------------------------------------------•-------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, and rules and regu tions of he San Joaquin Local Health District. (Signed) - --------------------------------- ------------------( / -- --- - -- ------------- ------------- ---------- Owner and/or Contractor) sY� ----------------------------- ---------------------- - - - - - Title ______________ __ (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY TION ACCEPTED BY-----_ -EDATE_ .r ------ 1� _..�-'D BY--------------------------------------- ------ DATE---------- ---------------------------------------------------------------------------- BUILDING PERMIT ISSUED--------------------------- ---- ---------------- DATE. ------------------- Alterations and/or recommendations__________________________________ ----------------------------------------------------------------------------------- ----- ----------- PERMITIdo._`_ -- - --7'-I- SUEDk-ikf1' ..----------------------(Date) FINAL INSPECTION- BY:-------- ------ ----------- Date_ --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W-1639 Stockton, California f