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APPLICATION FO,R SANITATION PERMIT 10117 (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. JOB ADDRESS AND LOCATION--------- ---- `1 ---- � = _ Owner's Name------------------------------------------ L{J -------------- f �----------------------------- PhoneOs-1----/-j--------- Address--------------------------------------------------J-44-V ----- { Contractors Name-------------------------- ----- 'f- —r--_ _r°�/7 C.�<------- Phone--j=--f; ?,7------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ (i' Number of living units: Number of bedrooms �f Number of baths Q] Lot size__p[B_r _-_�QQ-----________________________ Wafer Supply: Public system Mr Community system El Private El. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe JK Hardpan ❑ + ` TYPE OF INSTALLATION AND SPECIFICATIONS: V (No sepfic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material______________._----__-___--_-__-__-.-__________- — ---Liquid depth-------------------------- Cesspool: Distance from nearest we€1_________________Distance from foundation__________________-Lining material------------------------------------- , f ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_______.______________.___________.___-_. ❑ Distance to nearest lot li ___________________________________________ / r Seepa e Pit: Distance to pnearii eIL_ Q/----Distance drio�''dation_�___________.D�s�� to nearest lot line---------------- wit o- Number of ifs__-_____-_____-___-__Linin materia ---Size: Diamefer_________ _____________.De th_,._.T"_______________ _ Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_-______________ ❑ Number of lines----•------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material----------.--------------Depth of filter material_______________________ Remodeling and/or repairing (describe):- -------------------------------- ----------- -------------------------------------------------------------------------- --•-------------•---...-•----------------------------------- ---------------------------------- ---------- L ------------------------------------------------------------------------ ----------------------------------------- hereby certify that ha a prepared this a nd that the work will be done in accordance with San Joaquin County ordinances, S fe s, d r es and regulati San Joaquin Local Health District. (Signed} x f� -r--- ------- --- ---7w-C-11------------------------------------( Contractor) * JV -- --'- --- (Plot pi , sh mg"size of lot, location of s e in relation to wells, buildings, etc., must be filed with this.application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------ ---- DATE--------------I _- -- ----------- ------- ----------------- ------------------- - ------ ---------------------- ,, REVIEWED BY------------------------------ --- - - -- ---- - - DATE---------------'---- BUILDINGPERMIT ISSUED-------------------------------------------------------------- --------------------------------------- DATE---------------------------------------------------------- Alterations and/or recommendations--------------------------------------- ----------------------------------------------------------------------------•--•-•---•---------------------------------. --------•------------------------•--------------------------------------•-----------------------------------------------------------------------------------------•------------------- ---------------------------------.----_ -------•---•-----------------------------------------------------------------------------------------------------------------------------------------------------`-------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------•-.------------------- = -----•-- -=------------------- PERMIT No.__[-- _/- ---------- ISSUER-----------------------------------------(Date) FINAL INSPECTION BY:___ -•- � ---- Date-------------------------�f� ----ff---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California h E5-9-2M 9-50 W-1639