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YI APPLICATION FOR SANITATION PERMIT �q (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. 110 ------------ JOB ADDRESS AND LO TION -�--------- --------------------------------------------------------------------- Owner's Name-------------- ------------- ' -------------------------------- Phone-------------------- Address-----------------------------------3-4}� ------F---------------W�.-- -e� - ------------------------------------------------------------------------------------- Contractor's Name--------------------------1-A or K-------------------------------- ------------------------ --------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units: [� Number of bedroorns.3 Number of baths V Lot size-------5-4?-------x1,0Q________________________ , Water Supply: Public system Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic„iDl1� isfance from nearest well________________Distance from foundation--------------------Material____--------_____-_.________---_________---__- EKA__ (( [ of compartments--------------------------Capacity-----------------------Size--------------------------------Liquid depth----------------- -- ---- Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material-----------------------____._______- ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- ________________ _ Distance from nearest building-----_---_____________- Privy: Distance from nearest well__________________________ _ ___ ---------------------------------- ❑ Distance to nearest lot line________________________________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth------------------------__-1-- .Disposa field: Distance from nearest well------ ____Distance from foundation______�_�--____�_D.istar�te.-to-nearest lot;li�e_____ _______ Number of lines______:__________________ Length of each line__a(P10:- ---6D____-Width of trench-------------------------_--- Type of filter material__1--I }��1.�__Depth of filter material__*I.�,___!_F_11 Remodelingand/or repairing (describe):----------------------- '------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and' regulations of the San Joaquin Local Health District. (Signed)-- -------- ----------- ---------------------------------------- ------- --------------------------------------------------------(Owner and/or Contractor) - -t_ By: ------- z ------------------------------------------------ Ti+le---------------------------------------------------------------- (Plot plans, showing size of lot, location of system in to wells, buildings, etc., must be filed with this application). EPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ ----------------------------------------- DATE------ -- -- - - REVIEWEDBY----------------------------------------- ---- ----------------------------------- --------------------------- DATE---------------------- ------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------.----------------------------------------------------------------------------------------- --------------------------------------- ------- - -- -- ------------------------- -- ------------------------------------------------------- ---- --------- -- -- ------------------- ------------------------------------------------------------------- pp 77 PERMIT No. 1._-f ISSUED +� `rf (Date) FINAL INSPECTION BY: ----- - ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT (� 130 South American Street Stockton, California ES-9-2M 9-50 W=1639