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*' vF APPLICATION FOR SANITATION PERMIT v (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. 77 , JOB ADDRESS AND L.00ATION_� -�3e7 ------ : -----------------------•------------- ----------------------------------------- Owners Name = Phone_r _`- 4 4 r Address. Q f------•------ ------ '-----cC�-- ----------------- Contractor's Name ._..L1, % -- 07, ,,------------------------------------ ------------------------------------------ Phone-_ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: V Number of bedrooms J2 Number of baths 0 Lot size---sl' Q- -_k7 i Water Supply: Public system Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobv Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) "V Septic Tank: Distance from nearest well_________________Distance from foundation-----------._-.__--.MaterialEl -------------------- No. of compartments--------------------------Capacity-----------------------Size----------------------------•---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--:777=-----Distance from foundation---_�� Distance to nearest lot line_.- --d -----__Lining material_A!%f --Size: Diameter__.? r Number of pits--•-----�---- `-'_-- ___De th-- p �� Q,�------- Disposal Field: Distance from nearest well-----------------.Distance from foundation-------------------Distance-fo neares71ot line --'_ -_- ❑ Number of lines-------- ------------------ Length of each line----------------- '.___-------Width of trench Type of filter material-------------------------Depth of filter material----------------------- Remodeling and/or repairing (describe):-------------------_------_------------------____-_-_-_--___-_-_-. I i ---------------------------------------------------------- S ---------------------•--••---------•------•--- -------. --- -------------------------------------------------------- - ----•--------------------------------------------------------------------------------------------------------------------•------------------------------------------------------ ---San-------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (signed} , so--- ------- {�/or Contractor} - ---------------------- ------------BY� - ---- - - ---1 --------------------------- -------------- --- - -- ----------(Title)-- �/Go-2 - (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-_-_ ---------------------------------------------- ---f _ REVIEWED BY------------------------------------------- --- - ----- ----------------------------------------------------------------- ` DATE------------------ BUILDING .:------------- ----•-- - �-------•-------- t BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE --Alterations and/or recommendations----------------------------------------------- -----------------------•------------- ---- --------- ---------•------------------------------------------ ---------------•-`------- `T'`=-�-�----••--------6`------`-4---- `'L�---•----------- - ---------------------•--------- •----------------------------•------- --------------------------------------------------------- PERMIT No._ -1- ---------- ISSUED--Ia- ---� _ (Date) FINAL INSPECTION BY--------- ---------�---- Date----------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICTd "e�� °7 '�ve� jfiV`E✓ 134 South American Street b d` a I ES-9-2M 9-50 W-1639 Stockton, California r (,