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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 County Ordinance No. 549. JOB ADDRESS AND LOCATION---------------- e------ ----------eft-f-----------------1�3-------W------3-rd------------------------------------------- Owner's Name----------------ki-old------------ ------ ------- --- --------------- ----------------------------------------- Phone----------------------------------- Address-------------------------------------- CIA - %_11n---------------------------------------------------------------------------------------------------- Contractor's Name--------------------------------------- ----------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House E] Commercial E] Trailer Court [] Motel [:] Other 0 Number of living units- -El Number of bedrooms E2 Number of baths Ifl Lot si7e-----------Z11 r g Supply: Public system r" Community system E] Private F-1 UY Character of soil to a depth of 3 feet: Sand E] Gravel 0. Sandy LoaM-.F=],-Clay Loam E] Clay 0 Aclobeg Hardpan L] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is ava;lable'wifhin 200 feet.) Septic Tank: Distance from nearest well-------W_Distance from fou{dafion--------1-0-------Material-------------- ----------- .0 No. of compartments-------------)----------Capacity-------7'50__9---Size----- ---r__Liquid depth------r- ------------ Cesspool: Distance from nearest well_________________Distance from foundation--------_-----_----Lining material__________--____----_-___---_________ ❑ aterial---------------------- ------------- F-1 Size: Diameter--------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well____________________________ __________________Distance from nearest building------------------------------------------ 11 Distance to nearest lot line_______________________________________________ % Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line_______________ 4 ❑ -_ Z Number of pits----------------------Lining material-----------------------Size: Diameter__:_-------------------Depth---------------------- Disposal Field- Distance from nearest well-------Y�.Distance from foundation------M!,----Distance to nearest lot line-32--/---- Number of lines__________________t__X----------Length of each line--.2-o--------40 --Width of french--------- Type of filter material------)4---Y0 el�---Depth of filter material-------- . . I I 'Remodeling and/or repairing (de ---- ----------------------------------------------------------------------------------------- ,hcr -------------- -------------------------------------- -4--------e.;------- ------ ------- ---------------------------------------------- I--------------------------------------------------------------------------------------------------------------------------------------------------y---------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 regulations_ of the San Joaquin Local Health District. (Signed)- -------------- ------- --------- ------------------------ -----------------------------------------(Owner and/or Contractor) By:-----------------------------------------------------------------------------------------——---------------------------------(Title)---------------------------------------------------------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------- - ; DATE-------- b ----------------------- REVIEWEDBY------------------------------------------------------------------ --- ------------------------------------------------------ DATE----------------- -------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterationsand/or recommendations:--------------------------------------------------------- ----------------------------------------------------- ---------------------------------------------- ---------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------- ------------------------------------------------ -----------I- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- ------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------- - ------ -- - ---- ---------------------------------------- �r PERMIT ISSUED..... ---(Date) FINAL INSPECTION BY:___lie b -- I-%�------------- --------------- ------ ----- ----------------- Date---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES--9-2M 9-50 W-1639