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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. Q'T7-3zo-o,q JOB rADDRESS AND LOCATION _14L --1 'y- f-------*-- , Owner's Nar /5_1te----------- - Phone- "-fes Address----------------------- ' /4-I --' - ---------- Contractor's Name------------------'- `-- M1f- ----------P--h-o---n--p--.-1-----_-----------$--F------ - Installation will serve: " Residence Apartment House ❑ Commercial Trailer Court 1 ❑ ❑ Motel]` Other ❑ Number of living units: ) Number of bedrooms a Number of baths Lot size----- Water Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adoie Hardpa ,. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public serer is available within 200 feet.) Se ti Tank: Distance from nearest well__ - _Distance frgm foundation----__ -_ •� }.. "` tM"aterl-------- s No. of"compartments--__-_ --------- -----------Capacity_-- Q___---- Size-- -4�- p- Liquid depth- -' ------- ,- - Cesspool: Distance from nearest well-----------------Distance from foundation------____-_-----__.Linin q Lining material------------------ F71 Size: Diameter--------------------------------------Depth--------------------------- - - --------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---__-- --_-__---- ❑ Distance to nearest lot line -----__---- 0-All - - --------- Seepage Pit: Distance to nearest well_____________ _____Distance from foundation--------------------Distance to nearest lot line- ----------..1---- ❑ Number of pits-------------- ----Lining material----------------------.Size: Diameter f --------------------Depth----------=�,----------- •Tv Disposal Field: Distance from nearest well_ IC - Disfance from foundation__�' ( ---- . c__---Distance to nearest lot lin/� Number of linos______!--�___�___- ___---_ Length of each line-------�'-., Q--___f/.Width of french__-- .�_�-------------- Remodeling --- Type of filter material--/��etDepth of filter material---------�> _--_ -4 - 4 and/or repairing describe ------------- ----------- es- ------------------------------------------------------- ^` --------------------•------------- ------------------------------------------------- ------------------------------------------------------------------- ---- - -------- I hereby certify that I have pr ared this application and that 4he work will be done in accordance with San Joaquin C0UK- ordinances, St s, and ules regulations of the San Joaquin Local Health District. fy ! ` ., '�--------`�-------------------------------------- � (Signed) ------- ( " Qr_Contractor}' Yl ------------------------------ Tale - - -------------------- -- (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--- _ REVIEWEDBY --------------- ------------- -------------- ------------ ------------�------------- - - �`�---- -- --------. • DATE -------- ----------------------------`---" ------------ BUILDING PERMIT ISSUED------------------------- ----------- - ------------------------- - ----------- - DATE-------------------------- ----------------------------------- terations and/or recommendations____________________ -------------------------------- ------------------ ------------'--------------"------"--------'--"-------------------------------------------------- PERMIT _____----_____---__-------- --� I ----------`------------_---- °PERMIT No. ___---- ISSUED---- _�_�---_-.-------__-(Date) FINAL INSPECTION BY_____ _____ ___ _ *� ' ------------------------------------- Date---------------- J SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton,California FS-9-2M 9-50 W=1639 - `'�" ''"°' J