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APPLICATION FOR SANITATION PERMIT �' + (Complete in Duplicate) Application is hereby made to the San Joaquin Locaf Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 5149. JOB ADDRESS AND LOCATION__ { J �`'-.- ------ } ---- ----- ---- ----- Owner.s;Name----- -- ----- ------------------------ --------------•--------------------- ---- -------- Phone--- -- -------- ' .Address `---------------"'-------------------------------- ---------------------------------------- ----------------------------------------------------------- --------------------------- ------ -- -- �Contractor's Name----- -': = - ------------------- Phone----------------------------------- Installation will serve: Residence E]' Apartment House ❑ Commercial ❑ Treiler Court ❑ Motel ❑ Other ❑ % Number of living units: -❑ Number of bedrooms [4 Number of baths ® Lot size____________________________________ Water Supply: Public system ❑ Community system ❑ 'Private d R Character of soil to a depth of 3 feet- Sand ❑ Gravel ❑ Sandy`-Loam ❑ Clay Loam ❑ Clay ❑ Adobe® Hardpan ❑ } 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----4eT_f---Distance from foundation------LA--- ______-Material---------C ' -- -_____________tt.No, of com artments________"'��_______Capacity __Size fA__'�___[ t__. __f___Liquid depth____-Z-____________ Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material_____________________________________ 1 ❑ Size: Diameter----------------------------- ------Depth---------------------------------------------------- Privy: Distance from nearest well----_.____-_____________________________________Distance from nearest building________-_-____________________________._ ❑ Distance to nearest lot line__________________________ Seepage Pit: Distance to nearest welk----------------------Distance from foundation-------------------- istanco to nearest lot line_________________ ❑ Number of 'pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Disposal Field: Distance from nearest well -4!S_.(__.Distance from foundation-----?'2..........Distance to nearest lot line___:-r_.___._. ® Number;of lines----------- -.-___________________Length of each line---- - of french------�_e------------------- Type of.filter material__ _ _' ��C'±_ ZDepth of filter material______€_ `_'_________ - Remodeling and/or repairing ---------•--------------------------------------------- ----------------------- -------------------------- ---------------------------------•------------------- - - ---------------•--------------------•---------------------- ---------------------------------------------------------------- ---------- --- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--------------------- r-------.�__��---------------------------= = ------------------------------------------------- ----- ----- ------------------------ (Owner and/or Contractor) r By:---.__-.•-�-'-tom-°� ��-.��____.�___,,,.-------------------- (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-----------1A.1---V.-flo------- ----------------------------------------------------------- DATE------- " ------------------ REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------ . BUILDINGPERMIT ISSUED-------------------------------------- ------------------------------- ------------------- ----- DATE------------- ---------------------------------------------- Alterations and/or recommendations:-----_3_p_ _'_+3._1_.____'__' - ^ _._ _ .___/ ____�i ___ f�_-___� s_fs__ __________ ---------- ------------------------ --------------------------- Cd V#=--------------- � ----- rr -.---- Y tf ------ -------- - �/ - -------------------------------------------------------------------------------------------------- ----------- - ----------------------- -----�✓Q-----t► - ----.R.,f s - PERMIT No.- /-�---------- ISSUED--.--/---------9--------�77----------(Date) FINAL INSPECTION BY:--A----------------------------- _�----------------- Date------------ y--#---,q-------------- f_.. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street .,`¢' Stockton, Califofnia ES-9-2M 9-50 W=1539