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APPLICATION FOR SANITATION PERMITS (Complete in Duplicate) Application is hereby ! 'ade to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is mads' in compliance with County Ordinance No. 549. 1 IIII ,/ o� JOB ADDRESS AND L�IOCATION_ J T Owner's Name------- ----=----------------A-k-V-'------CARD_--------- --------- ------------------ ------------------------ ------ Phone------------------------------------ Address------------------------- ----------- 5--t-�-_jba-z 7/ III -a-�,/_O__e----r-------- ---------- Phone Contractor's Name______11 Installation will serve: iiResidenceApartment House ❑ Commercial E] Trailer Court ElMotel E] Other ❑ Z- 'C - o--' - Number of living units: F-1 Number of bedrooms I� Number of baths Lot size________ _____-_ --- ------------ --- Water Supply: Public- system ❑ Community system ❑ Private ❑ y ❑ y Adobi)e Hardpan Character of soil to'a,��epth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Cla Loam Clay ❑ ❑ TYPE OF INSTALLATIIION AND SPECIFICATIONS: (No septic tank) or cesspool permitted if public sewer is available within 200 feet.) , d1if' le Se tic ank: Di�tance from nearest well_____ _________Distance from foundation_____ Mat5� erial____ -� -��--- Nb. of compartments---------------------Capacity--- U -------Size---___ �C �' 7 Liquid depth ;II -Cesspool: Distance from.nearest well_________________Distance from foundation____:______________.Lining materia-------------------------------- Sile: Diameter--------------------------------------Depth--------------------- ----------------------------- ----------------------------------------- 4 Privy: Q.i,stance from nearest well---------------------------------------- Distance from nearest building, ❑ Distance to nearest lot line------------------------------------------------ II: Seepage Pit: Distance to nearest well_--___.______________Distance from foundation--------------------Distance to nearest Iofi ine________________ ❑ Number of p-iits------------ --------Lining material-----------------------Size: Diameter Depth c II Disposal,Field: r ____Distance to nearest lot line____-_ ___�'_ � � _Distance from nearest well__________-Dist �m foundation____t�------ "} _ ,?IJ idth of trench----------�t-�- ---------- NI mber of lines-------�'-� ------ ----- Lengt of ea4+ --------,-------- Type of filter material________l�� Depth of filter mafierial____-_1_ ___�_______ i,I Remodeling and/or }' airing (describe):------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- ------------------------------------------- ------------------------- ------------------ --------------------------- ---------------------- ---------------------- ---------------------------•-------=------------------------ -------------------------------------------------------------------------------------------------------------------------------- I hereby certifyil'�that I have prepared this application and that the work will be done in accordance with San Joaquin County .f ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. II' : _ _ (Owner and/or Contractor) (Signed) T'tl �Y� �- ------------- ---• _------------ - - ie (Plot plans, showing y ze of4ot, location of system in relation to wells, buildings, etc., must be filed with this application). II FOR DEPARTMENT USE ONLY r _ DATE-----__ --------------------- APPLICATION ACCEPTED BY__________________ __ ___ REVIEWED BY-------- ----- - ----------------------- ------------- --------------------- DATE BUILDING PERMITIJISSUED--------------------------------------------------------------- -------------------- DATE Alterations and/or recommendations-------------------------- -- ----------------------------------------------------------- -----------------'------------------------------ ---- ------------------•--------------------- -------------------- ------------------------------------------------------------------- --------------------------------- ---------- ------------------------=------------------------ -------------------------------------------------------- ------------------------------------------------------------------------ J[-------------------------- --- ----------- ----- ---------------------------------------------------------------------------- ----------------------------- - - ----- ---------- `r _(Date) FINAL INSPECTION BY: PERMIT No._--U--- ,t; ISSUED I 5 - f iDate-----------/P---- - f----------------------------------- I . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-11-2M 9-50 W-1639