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APPLICATION FOR SANITATION PERMIT r� r2. r7 1 � � (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. JOB ADDRESS AND LOCATION----------� SNr--------,-rbj2�L-4eu3_�----------------------------- _ _ - Owner's Name---------------- Y -M -------- --------------- Phone-- ------------------ ------------ Address � ---------------------------------------------------------------------- Contractor's Name---------------- � +--------- ----------------------- Phone--------_'7'"'""_"'""„ Installation will serve: Residence Apartment House El Commercial El Trailer Court ❑ Motel El Other ❑ Number of living units: Number of bedrooms 3 Number of baths & Lot size---------- Water Supply: Public system Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel [❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Aclobelfr Hardpan ❑.�\1 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____rQ___Distance from foundation----J_Q-------.Material_______ No. of compartments----------------------Capacity_1_4-Qd-------Size_.-_YY_ h____.-__1j6—___Liquid _ --------- - 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 iine________________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------_-----------------_------ Disposal Field: Distance from nearest well______JV__Distance from foundation-----(_ __ Distance to nearest lot line_____-�_____ Number of lines_____________1----i--------------Length of each line-------4.O' ------------Width of french------- r/ Type of filter material ` _�rQ -----Depth of filter material______1-0`,-_---,___ Remodeling and/or repair ng (describe):-- -____--- -QA -_- -Ap_.! a �. � ------------------------------------------------------------------------------------------------- i --------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and' regulat'ops of the San Joaquin Local Health District. (Signed).................. -------�-�-- ------�-�-- ------------------------------------------------------------------------------------{Owner and/or Contractor) By:---------------------------------------------------- - - Title - - ---------------------------------------------------------------- P of plans, showing size of lot, location of system in relafion to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY______________________ t "o --- -- -------- - ---- DATE r 7 \f REVIEWEDBY---------------------------------------------------------- - --------------------------------------- DATE +- -`-- - ---------------------- - BLIILDING PERMIT ISSUED ----------- ------------------ -------------- ------------ D,ATP-------------------- �---------------- . - Alterations and/or recommendations-------------------' ` � = � ='v„ ----------� .1 Y ---------- ------------------------- -------------------------------------- PERMIT No. --- __-- ISSUED__!_ /��/----------(Date) FINAL INSPECTION BY:-------U W ---------------------- � , Date---------- •----- - -``-'-�-`----'-s---��'— ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street E5-9-2M 9-50 W-1639 Stockton, California