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APPLICATION FOR SANITATION PERMIT f (Complete in Duplicate) V 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 Counfy Ordina ce No. 549. JOB ADDRESS AND OCATI N- ------------- ; ------x_1.1 ' e:e------td----'�-------------------- r Owner's Name_________ '`- '�.r -- -- ------------------------------------------------ Phone Address ---------- - --- ---------S-4 Contractor's Name,-.- ----------------------------------------------- y� -- ----- ------------------------------------- Phone--------------•------------------- Number ------- --- -- -- ---------------------------------------- Phone will serve: Residence Apartment House C1 Commercial [ - Trailer Court Number of living units: ,h Number of bedrooms ❑ Motel ❑ Other [I Number of baths � Lot size__---_-_ ____ f ` Water Supply: Publics stem Pp y' Y ❑ Community system❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe PO/Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic ank: Distance from nearest well--- _�_ t 1 Distance fro_ foundation------ --------.Material__-M'! __I--__-- No. of compartments-_-___---_-�--------Ca aci $ p tY Srze_ a Liquid depth--_-=---- n- f Cesspool: Distance from nearest well ❑ Size: Diameter _____Distance from fouridation___---__---___-___.Lining material.---_------__----_-_-----__ _ = ----------------------------Depth__----------------------- "Privy: Distance from nearest well----------------------------- i ______-------------Distance from nearest building ❑ Distance to nearest lot line g ------------ g ee ag Pit: Distance to nearestell____ Number of pits- ____----_-Distance fromoundation----- ---------Distapce to nearest lot line-_--S 1 ------- ------------Lining material__I�t�-_._--_.Size: Diameter-_--- f - ------------- ��'---�+.� .Disposal Field: Distance from nearest well----------------- Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number oflines-----------------------------------Length of each line--____-------_----__ Type of filter material---------------- Width of trench__-------------------------- Remodeling ---------__ --____---Depth of filter material------------------,_ ------------ ------ r Remodeling an /orrep iri g (d Crib ):_-___--_ 71kk"5 ------------ A—------------ 4-4, fvh --------------�lWi- • - cPt, rs-p ---:--------------- - -b----- E - -� io --------------------------------------------------------------------------------------- - -- -- 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 LocalHealth District. (Signed)--------..- ------------ �j ------------------------- --------- , ---------(Owner and/or Contractor - -----•-------------------------------------- - ---- -- --------(Title)----------------------------------- P of plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). ------------------- F DEPARTMENT USE ONLY --------------------- APPLICATION ACCEPTED BY----___------------- - - - 9 REVIEWED BY DATE_ � _ BUILDING PERMIT ISSUED ------------------------------------------- ----- ------------ ---------------- DATE- _ ___ ------- ----------- ----- ------ -------- DATE------------------- Alterations and/or recommendations----------------------- ---------- ------------------------------- l r yI PERMIT No._.--p- `----------- ISSUED---io__.-tY�-"5- ---------------------(Date) FINAL INSPECTION BY:---- Date = C. --- --'e"—? --------r'�r--/----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W-1639 Stockton, California .