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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Applica ion 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 co m iarice with,County Ordinance No. 549. 47,W,, M JOB ADDRESS AND LOCATION-------------- /,_0MJ, iC � eo Owner's NameA gry ----------------- Phone------------'--------------------- C Address = - ----- - --- ------- , - ---------------------------------------------------------------------------------- Contractor's Name-------------------- --- .� g/� �!t?- f Phone f� C/ .c/ C.e Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .It Number of bedrooms . Number of baths ❑ Lot size-- 070 1 3 D- Water Supply: Public system ❑. Community system ❑ Private ❑r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe ❑ Hardpan ❑ r TYPE OF INSTALLATION AND SPECIFICATIONS: s (No septic tank or cesspool permitted if public sewer is available within 200 feet.) p ! Se tic Tank: Distance from nearest well___�______Distance from foundation______d_________.Material_______________-_____ _________ _ No. of compartments----------�'----------Capacity-- -CO-Q-------Size-_Z_K- X ------Liquid depth------ -Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-----------------------------._______ ❑ Size: Diameter--------------------------------------Depth--------------------------_------------------------ Privy: Distance from nearest well---------------------------------------------_:-_Distance from nearest building----------,-_________________----- - ❑ Distance to nearest lot line_____________________________--_ ------------ 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 founclation___��_/_______ -------_Distance to nearest lot line-, ____________ Fir Number of Lines--------�"---------------------Length of each line----------- --- -� -- Width of trench -'""" " r _ ' > Type of filter materiall - ---------__-Depth of fidter material-------�� - Remodeling and/or, repairing (describe)---------------------------- ------------------------------------------ ------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------- ------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accor- dance- - with San Joaquin County ordinances, State laws, and rules and' regulations of the San Joaquin Local Health District. (Signed)------ P� _dv 5 '-------G-Q----------------------- -------•------------------(Owner and/or Contractor) q BY -=---- ------ --------------------------------------------------(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 APPLICATION ACCEPTED BY_____-______________ _ _ DATE________ _ REVIEWED BY------------------=----------------------------- ,------------ ----------------------------- DATE-------- - -ti--: ------------------------------- B DING PERMIT ISSUED--------------------------------------------------------- - -------------------------------------- DATE �t i s Rnd4q r 'endation - -- ------------ - -- ---------- - ---------- � q''` �,.. E E�S��C►ti Celt 4:.� a-t ``3[ " =�er 1 `------------ S f Liz j --------- PERMNTIo. �f--- --- ISSUED------- -��-{ ------(Date) FINAL INSPECTION BY---- ------------- -------- ------------------------------------ Date ------------- - - -- - Date - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ~�E5�9---2 tv1 9-50 W=1639