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APPLICATION FOR SANITATION PERMIT 'p 9 (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 L----- ele------------------------ 4 Owner's Name-----------------------------------------------------'-- 1-45--•----- - AG-il.deo-1-C ---------------------------- Phone-,O.�-4x 49 ---- Address Contractor's Name---------------------------- � ' � "F 4`�a : -�� -------------- Phone- Y=- �-Q-7--------- Installation will serve: Residence, Apa timent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f ^ � Number of living units: Number of bedrooms Number of baths Lot size___________ ________________ Water Supply: Public system K Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) y eptic Tank: Distance from nearest well_________________Distance from foundation-------____________-Material-_________________.-_----------____________-___ RX]'_�' _ I 4''h No. of compartments--------------------------Capacity-----------------------Size--------------------------------Liquid depth-------------------------- Cesspool. Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- F1Size: Diameter--------------------------------------Depth---------------------------------------------------- Privy: -------------------------------- -- -Privy: Distance from nearest well_________________ _____________________-________Distance from nearest building____-____-_______________--__------_---_- ❑ Distance to nearest lot line________________ _______________________________ pag Pj Distance to nearest well----------------------Distance from foundation-------------------- to nearest lot line_________________ Number of pits----------------------Linin material-----------------------Size: Diameter------------------------Depth--------------------------------- I Disposal Field: Distance from nearest well ______.Distance from foundation' p ___ i � __---------Distance-to nearest lot line_-_--_- -� Number of lines___r_________ _ ______ _ Len th of each line___ ------ }�i� t}C 9 -�Q--'-----��-----Width of trench---�*tt`�----------------- Depth - ------- Type of filter maDepth of filter material-------# _-_-_--_- , Remodeling and/or repairing (describe)__________ --- __r__s_-Q__ - �`L-Jlii4+ -------- - ----------- r --------------------------•--------------------------------- -----•- _ V ---------------------------------------------------------------------------- --------- ------------ - ---------------- ! # -------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certifylof ve prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat lales and regal ' of the SaJoaquin Local Health District. 5i ned - Contractor) BY: �� (Title) X�/�� ?(Plot plans, sh g size lot, Iona+ian of s tem in relation to wells, buildings, etc., must be;filed with +his application). s ' FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY------- -------- ----------------------------------------------------------------------- DATE----1 - REVIEWEDBY---------------------------------- ------ `---- ----- -------------------------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------ ------------------------------------------------------------------------- DATE---------------4,'----------------------------------------- Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------�-------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - ------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------- - ------------------- ------------------------------------- ----------------------------------------------------- - -------------------------------- ---------- ------------------------------------------------- !o - PERMIT No.- l-- �--- ISSUED--------- �� ` J 1------(Date) FINAL INSPECTION BY:- - -_ ------ Date_ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 4-50 W=4634 ��