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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) I 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------- Owner's Name------------------ Phone__, Address------ ...... f�i.lj, Contractors Name...... ---__�____ _ _ ----` ` -- --------------------------------------------------------- Phone- Installation will serve: Residence A artinent House r6ommercial r p [] ❑ Trailer Court ❑ /Myo�tel ❑ Other ❑ g m � oms Number of baths Lot`size------�U_!/_�_ _ _ i9 _________________ Water Supply: Public system Community s st'e� � t � �� Number of living units: Number of b dra PP Y Y ❑ Y yt m;❑ ;'Private v �I Character of soil to a depth of 3 feet: I Sand'E] (;Gravel k Sand. Loam Clay Loa Cla Adoba Hard an 4 P ❑ ❑ Y ❑ Y ❑ Y ❑ P 1�� TYPE OF INSTALLATION AND SPECIFICATIONS- n septic tank or cesspool permitted if public i wer'is available within 200 feet.) Septic Taj p k: Distance from nearest well ___._Distance from found ion_____ _ t ___.Materi;31_____- _ _ __ ________- No. of compartments___________ __ ___':Ca aci 170__ Size_. =_--------------- � �Inr� - -_ - �F tY------� --11, _- � -----.Liquid depth--- �,-------------- Cesspool: � ------ Cesspool: Distance from nearest well________ ___,,Dist nce from foundation__________-._____.Lining material-------------------------------------- -1 Size: Diameter--- -------------------- ==- 'De .h = Privy: Distance from n6a"'rest well_________________ri_= \_-___.____- -_-�____Distance from!nearest buildin --________-____ -- -------------------------- ❑ Distance to nearest lot line---------------- _:----------`----__---- .- ) .. Seepage Pit: Distance to nearest well .b_a__Distance fro r�--`foundation_____!B!�'--.Distance A Barest lot line__-- '� c. , Number of pits-------{--f____----Lining maten)al- - �Size: DiQ ,r__----��_ .---- p+h------- ---------------- ' P' Disposal Field: Distance from nearest well___ P Distance from foundation____ ___,__.__.____Distance to nearest lot line____ U_.____ Number of lines-----_----------l�`_ - Length of each line``' � D•'-_` Width of trench__x��_0------------------------ Type of filter material_ - Dep+'fi of#il'ter material__ '_ _----____ Remo a ing and/or repairing (describe ------- -- ---------------------------------------------------------•----------------------- - _'---------------------------------------------------------------- ' --------------------------------------------------------------- ---------- ---------- SV_ _____W_ . _�_____-� - ------------------------------------ -------------- � � ------------------------------------------------------------------ I hereby certify that I have prepared this application and thatthework will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaqujn Local Health District. (Signed)------> r -- ---------' ' ct'�.��,—__. r = -(Owner and-or Contractor),. BY:------ --- - '-------- -*a�y - _`► �Plo�"p`1ans, showing size of to --------------------------- ;location of system m relation to wells, buildings, efc.,must be filed with this application).� , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- -- ------- ------- -------- = -------------------------------------------- DATE-------,OG- ' --`S'O BUILT)NG PERMIT ISSUED. ---- ---• "'--- '--- -------------------- --- ----- --------- ------ DATE------- �--------4-° ..�. DATE ---------------------------------------------------- Alterations and/or recommendations----------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------•--------------------------•---------------------------------------------------- ----------- ------------------------------------=--------------------------•---------------------------------------------------------------•-------- --•---------------------------------- ------••-------------------•-------------------------------------------- ------------------ ------------------------------------------------------------ ----------------------•---------•------- PERMIT No-----x_Tr---------- ISSUED___ --- -_-----(Date) FINAL INSPECTION BY:_____-__�---__ �'?!_ Date-------------------lQ jf-SA SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California E5-9-2M 9-50 W-1639