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APPLICATION FOR SANITATION PERMIT } (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health District for This application is made in compliance with County Ordinanc No. 549, a Permit to construct and install the wank herein described. JOB ADDRESS AND OCATION__"__"/___ VC Owner's Name-_.._:d 46,-- ---------------- Address ---- ---- - -��_ ��-------- Phone------ ------------- ------- ----- --- ----------------- ----- ------------------------------------------------------- Contractor's Name____ R - ' {_ ---- -------------------------- Installation will serve: Residence ` I-------------------------- Phone___"__ (j"" A artment House ❑ `� Commercial Number of living units: ❑ Trailer Court ❑ Mofel ❑ Other [] 9 Number of bedrooms V Number of baths Lot size_"_" Water Supply: Public system Community system Private X-4 0-0 ------------------------ Is Character of soil to a depth of 3 feet: Sand ❑ ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe lgr TYPE OF INSTALLATION AND SPECIFICATIONS: Hardpan E] ",-I.< (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ` Septic Tank: Distance from nearest well _Distance from foundation__-___ X No. of compartments-__._--_.?„-_ --------Material____ __ ___ -- ---Capacity-- -�Q[a G - -p - -- ----- ------------- ----- -- -----Size----��r---x��--------Li aid depth --------------- Size: _ -------- Cesspool: •� p Distance from nearest well-----------------Distance from foundation --------- Lining material_______-_-"_"__�__ "-_"_ ""-_"" ❑ Size: Diameter_--_•-- -- -- ---- Privy: ---------Depth Priv - ---------------------------- - Y� Distance from nearest well___"_______________ _ Distance to nearest lot line------------------------ _Distance from nearest building - ---------------------- eepage Pit: Distance to nearest well_- �__ _Distance from foundation_" _ - Number of pits__-__-___�""____,__Lining material__ _ "��-- - -or Distance to nearest lot line""I '� '® --- t_Disposal Field: Distance from nearest well__-_------Distance from f dation___ f ler" De th___ Number of lines_____--______—/__"____,r _ Distance to nearest lot line---s. ---- Length of each line ------- Width of trench____ Type of filter mafie _ f Depth of filter material_______ �'"�,"" emodeling and/or repairing (describe):---------------------- -------------- : - ------------------------------------------- ---------- ------------------------------- ------------------------------- -------------------------------- ----------------------------------- --------------------------------------------------------5.-------•--------- / ---------------------------------------------------------------------------------------- _ I hereby certify that I have prepared this application and that the work will-be done in accordance with San Joaquinunf},, ordinances, State laws, and rules and regula+ions of the San Joaquin Local Health District. e(Signed)----- 'k- r' -------------- By: . -------- - - - --------------------------------------------- ----------- __"____- ---__-•--c7"----- ---- --- --- - [C9wreer-end or Contractor) --------------------------------------------------- ( ) '_ / (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc,, mustTbelefiled with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY , ,.� DATE--- f REVIEWED BY--- "________ -- ------ - ------ -------------- ------------ 1 ------------------- ------------- ----- --------------------- - f__:�_ - -- -------- BUILDING PERMIT ISSUED DATE --0- f - ------------ ----------------------------------------------------------------- DATE IF Alterations and/or recammenda+ions:_ _ -- ' ______________ ______________________ __________________________ _ ______________________________.______-______ PERMIT No.._ __ ___�"-_"_ ISSUED_____ l_�' ___________________________ /�---------- Date) FINAL INSPECTION BY:___"- 0" ` Date a •------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street E5-4-2M 9-50 W4639 Stockton, California i