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APPLICATION FOR SANITATION PERMIT (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 Cou ty Ordinance No. 549. // JOB ADDRESS AND OCATION /A/Z11464 ------- ------- gQ, Owner's ---&_4 y--- ------------------------------------------------------ Name____ ____ /_l -�Cl- D/f-_ -_ / pp �� ------------ Phone_ ------ Address--- --------------------- lr ' � nn Contractor's Name 1�r� � ''==' �` AAJ --- .r_- Phone ----------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms Q Number of baths ® Lot size.S�_!f' Wafer Supply: Public system ❑ Community system [] Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 23 Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)' Septic Tank: Distance from nearest well________________Distance from foundation-------------------.Material ----------------- ❑ No. of compartments--------------------------Capacity-•---------------------Size-------•----------------------- Liquid depth------------------------- Cesspool- Distance from nearest well-----------------Distance from foundation--------------------Lining material__________________---,________-____ ❑ Size: Diameter--------------------------------------Depth------------------------- -------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-________--____________-__________--_-_ ❑ Distance to nearest lot line________________________________________- -__-- Seepage Pit: Distance to nearest well __-Distance rom fo c�tion___________________.Di t9nce to nearest lot line-- Number ig_____ _.___-_� 7Q. Number of pits_______ ________Lining material 441[I�..lpl�ve: Diameter_ _-____________.Depth-_- ----�------__�-- Disposal Field: Distance from nearest well------------______DisfVce from foundation--------------------Distance to nearest o�lin Number of lines--------------l-.__-______________Length of each line__' --------------Width of trench ___ _ --T d- -------------- Type of filter material_________________________Depth of filter material----------------------- �' Remodeling and/or repairing (describe):---------------------------------------------- ------------------------------------------------------ , ---------------------------•----------------- ------------------------------------------------------------------------------------------------------------------------------------•------------------------•---------------- I hereby certify that I have prepared this application and fhat the work will be done in accordance with San Joaquin County ordinances, State laws, an rules and regulations of the San Joaquin Local Health District. (Signed)_ -,574-.-.- � , (Owner and/or Contractor) BY= w/ _ ! - --------------------- �''� {Title} (Plot plans, showing siie of lot location of system in elation to wells, buildings, etc must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- ! C„-------------------------•----------------------- DATE------------------ _.� --- ---------------------------- REVIEWED BY----------------------------------- ------------------------------------------------------------------------- DATE----------------- -- DIN PERMIT ISSUED----- ------------------------------------------------------------------------------------------------ DATE------------ ------------------------------------------- Alterations and/or recommendations-,----------------------------------------- -------------------- ------------------------------------------------------•--------------------------------------•---------------------------------------------•---------------------------------- ------------------------------------------------------------------•-------------•----------------------------•----------------------------•------ ------------------------ ------------- ------------- PERMIT No---------- 4_••------- ISSUED---------I--o--- 515-0------------(Date) FINAL INSPECTION BY:-------------- -- ----- Date- ----------------------------------- --- - --- ------------- SAN - ------SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California E5-9-2M 9-50 W=1639