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APPLICATION FOR SANITATION PERMIT in Duplicate) (Complete P ) Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work her in described. This application is made incompliance with County Ordinance No. 549. 1 1 I JOB ADDRESSrAND LOCATIO / ._�L' (-3 ' _ f-----------�---- q�°-' ` i _ �'-- Owner's Name-------------------- t � - -- -- Pho4.ne - -------- ' \ Ax /` U '�e�`r�� = ------- ----- -------------------------------------------- Address_ _ • • r r ---------- - 1 1C ' :sem U ry—y1 6 l' f .------ Contractor's ,� __=n --- Phone--- r 7------ .Name______. .__ _ Installation will serve: Residence ❑ Apartment House ❑ Commercial K Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths A Lot size___.-_/-----___'-'t____7-1 --"__----__ Water Supply: Public system g 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 ublic sewer is available within 200 feet.}7� p � __Distance fro found 'On ;_,. I CA Material..._ ___ ____+. Septic Tank: Distance from nearest well_ G� ----- Capacity. j____-Size_4T--•--- -----------Liquid depth_---"----- No. of compartments______. 4 F Cesspool: Distance from nearest w II_________________Distance from foundation___-______-_____._.Lining ma-ierial------------------------------------- ElSize: Diameter--------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well_________________ ____;___________--------------Distance from nearest building_______- . _.____________-_________________-� ❑ Distance to nearest lot line------------------------------------------------- ,y Seeps e Pit: Distance to nearest ___-__Distan� .jf o fo ndafion t r'f___.D�i ante to nearest lot line.-6___'F Number of pits------- _------.--Lining material.4 '-_` __Size: Diameter____T _---------Depth--- �- _ - sr Y F. , - `!"�r, Disposal Field: Distance from nearest well. K ___.Distance from foundationr'�`_�__-'-______Distance to nearest lot line__ ____-__.-_ Number of lines______4____-_;___�,____.____--Length of each line_____ d ---------Width of trench___,P_C_4..................... Type of filter material__j "� _______Depth of filter material______-_/.e---'___- Remodeling and/or re firing (Jest e): --- --------- ---- --- ----------------------------------- ------------ ---------------------------------- -`-� --- —------------`--I------------------------ ---------------------------------------------- --------------------------------------------- --------------- ------ -------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County k ordinances, State laws, rules and r7lion o the San Joaquin Local Health District. Si ned -----t ---- _ Owner and/or°Contractor By:-------------•-------------------------------------------------------------------------------------------------------- {Title} � ff,e• F� ¢ (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be file with this application]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE---------------- A__l _ �--------------- IREVIEWED BY------------------------------------------------------------------------ --------------- -----------------'------------• DATE C( BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------- DATE-----------------------•----------------------------------- Alterationsand/or recommendations-----------------------------------------------------------------------------------------------------------------------------------------------------•------- ---------------------------=------------------------------------------------------------------------------------ --------------------•------------------------------------------------------------�------------------ •--------------------------••---------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ --------------------------------------------------------------------- PERMIT No-----�lpfa ISSUED_ __�- _- --------{Date) FINAL INSPECTION BY:j�'�'- ---- Date-----------------�1-b J -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639 I�