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'APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health Dist ric four.a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 54 , JOB ADDRESS AND LOCATION------ •--------- -- ------------------- IL Owners Name________________ __ p., ' ` ---------------------------------- --------------------------- Phone- r ' Address------------ - --------- a------------------------------------------------------------------------------------------- -t/�r _ Phone----------------------------------- ► Contractor's Name--------------•-------------------------L-- installation will serve: Residence 12 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 _ U----------------- Number of living' units:-1] Number of bedrooms P Number of baths [� Lot size_____________ __ __�____-- - --- Water Supply: Public system ❑ Community system ❑ Private` ? Character of soil to a depth of 3 feet: Sand ❑ Gravel El Sandy Loam ❑ Clay Loam C] Clay ❑ Adobe. Hardpan ❑� TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 0 1 5eptic�Tank: Distance from nearest well Distance from foundation--------------------Material._--__-___------_-_---------------------------- ---------Ca acit _Size--------------------------------Liquid depth---------------- - ~-I]t��f 7r�w No. of compartments---------------- p Y----------------- ---- Cesspool: ! Distance from nearest well-----------------Distance from foundation-------_----_______-Lining material-_---__--_--_-----__--_-_-------_-__ -_De th--------------------- -------------------------- � ❑ Size: Diameter--------------------------=-------- p - --__----Distance from nearest building---------------------------- �"' • �-Privy: Distance from nearest well--------------------------------------- - - j ❑ Distance to nearest lot'line------------------------------------------------ Seepage --___-------------- -------------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----_---____----_ ❑ Number of pits---------------------Lining material_---------------------Size: Diameter-----------------------.Depth--------------------------------- from foundation--------------------llDistance tnearest lot line------------ Disposal Field: Distance from nearest we -----------------Distance '- ---Length of each lire----------------------------- trench of trench---------------------- ------ 4 ❑ Number of lines------------------------------- t Type of filter material of filter material----------------------- � r --� . - = Remodeling and/or repairing (describe):---------------------- --_- ------ • ------ ---------------------------------------- --------------- ------------------------- --------- ----------------------•-------------------------------- y ---------------------------------------------------------------------------------------------- I herebycertify 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. ------------------------------------------------------------_Owner and/or Contractor] [Signed]------ --��'--°---------• .-- ;---..- •-- - - -\61 (rile}------------------------------------------------------- ----- By:--------------------------- ------------------------------------ ---- ------------------------------------- (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 i --------------------------------------- PATE----------�--'�--=---------�---------=J----------- APPLICATION ACCEPTED BY------------------�-- -- l ----_---- — ----------- DATE----------------------------------------------- REVIEWEDBY------------------ - ------------------------------ - --------- --------- ---------------------- ------------ --- DATE------- --------•------------------------------------------- Alterations ----- ---- - , BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------- -- - -- ---------------------------- Alterations and/or recommend ations:___-___-_------------------_-----------------.-- ------------------------------------ -------------------------------------------------------------- ------------------- ------------------------ -------- --------------- --------"-------------------------------------------------------------------4-------- ------------------------- PERMIT No *1_A -,-l- � / 7 ,f � ----(DateFINAL INSPECTION BY----------------------------------------------------- ---------- T -- ISSUED----- - ----- - ------ ------- ( ) Date------------------------ -------•------------------- SAN JOAQUINLOCAL HEALTH DISTRICT ' 130 South American Street Stockton, California ES-9-2M 9-50 W-1639 ""