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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__ -TQ__---_ -- Owner's Name------------------------------- kI'Z----- Phone _��- --3--------- Address 0- -NO ca_&-Q-------- -------------------------- - Contractor's Namey '\ © C� ;'V----------------------------------------- Phone----9�-7 / Installation will serve: Residence 5J Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: [4 Number of bedrooms [2--Number of baths U� Lot size___ ---------- ater Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe K 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-3. `-----Distance from foundation--------------------- _____ � --C n ' � O Ad ---- Material,?� � -Co^� - i ®. No. of compartments_____ o-- / �� `� Capacityoa- aC_Size ------------------ Cesspool: " Liquid depth ` Distance from nearest well_________________Distance from foundation_______ ..Lining material______--_______- _________- ------- Size: Diameter--------------------------------------Depth-------------------------- Privy: Distance from nearest well_______________ -----________-Distance from nearest building 9 ------------- ❑ Distance to nearest lot line I I `- -------------------- -- - ----------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line__-__,___________ # ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- Disposal Field: Distance from nearest well-$_______-__ Distance from foundation___ �_Q-__--- .Distance to nearest lot line------ ®. Number of lines-----------f Length of each line____�__-a 2-11 •� Width o{ trench Type of filter material_-� ��+----_-_-_---Depth of filter material_____/ Remodeling and/or rep (describe):___.________r_______ _--�______________ // �� --------------------------------------------------------------------------------- ----------------------- - - - ----------- 20,0-- ---- --- - ------------------------------------------------------------------ ----- --------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and tha} the work will be done in accordance with San Joaquin County ordinances, State law , and rules and regulations of the San Joaquin Local Health District. (Si ned 9 ) R- - 3r ------------ �` ----- By: - -- __ ---------(Title) Contractotf (Plot plans, sh' wing size of lot, location of ystem in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-______________________________ _ ------------------ DATEIEWED BY - ------ -- ------- -------- -- ------ --- -------- DATE---- -- ------- -------------- UILDING.PERMIT ISSUED------------------------- DATE ---------------------------- A terations and/or recommendations_ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------- PERMIT No >_ ----- ISSUED___` / _a'�_S:/-----(Date) FINAL INSPECTION BY:--------I _-✓-- ------------- Date-------------------- __47) SAN -4-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W-1639 Stockton, California