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z• 3v �� ,j.5 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. _a / Q Q ----4j�------------------------------------------------------------------------------------------- JOB ADDRESS AND LOCATION_______________ � ----- ' �� Owner's Name------------------------------------------------1mnes-------13-A-Ro-ri---------------------------------------------------------------------- Phone---- --0W_ _-17E------------- -40 Address---------------------------------�--_-:-_-_-_-----t-_-_ _ - _ - �-_----r- ' ------4K ---=Ql- -��0 Contractor's Name_________ i---------- - ---- - Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Z Number of bedrooms EK Number of baths [t Lot size___I—.-_Q`___.?<------/1 d---•--------------------- Water Supply: Public system ❑ 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 public sewer is available within 204 feet.) Septic Tank: Distance from nearest well-________-_____Distance from foundation___________________-Materia______________ ________--_-_____________- ;, 5bl-1717 No. of compartments_____________.____ CapacitY Size Liquid depth Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining materia ________--- - ------------- ❑ Size: Diameter-------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_________------------------------------- ❑ Distance to nearest lot line------------------------------------------------ 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__40WAistance from foundation___ �_ _____.Distance to nearest lot line`_"J__________ ® Number of lines----------- ---------------------Length of each line-----_4 0---------------Width of french-------2--T----------------- Type of filter material----/A-__"/?/%---Depth of filter material------- /N/T7C'f2 � ie'�td2_09 7__gr-----------------------------------•-----------------•------ -Remodeling and/or repairing (describe)________________/��-._____----- _ -----------------------------------------------------------------------------•-------------------------------- -------------------------------------------------------------------------------------------------------------- ----- - - ---- --- ------ --------------------=---------------------------------------------------------------------------------------------------------------------------•------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law , and rules and regulations of +he San Joaquin Local Health District. Si ne( d)---- s ._ = ------------------------------------------(Owner and/or Contractor) g L r� By:------ �-A-1L- -- - (Title)-- ---� i_C1719_. P2 (Plot plans, s6 wing size of --- -lot, 1peation of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------- i_;I __ __ DATE----------------- -- f REVIEWED BY-------------------------------- - l DATE--------- ------- �j --- = _ BUILDINGPERMIT ISSUED---------------•----------- ---- ------------- DATE------------------------------------------------------------- Alterations and/or recommendations--------------------------------------- - -- -------------------------------------------------------------------- - ------------------------------------------------------------------------------------------------------------------- -------- --------------- --- ----------- ------- ------------------------------------- ------------------------------------------------------------------------------------------------------------ - - - - - -- -- - '! � 5------- --------(Date) FINAL INSPECTION BY:-------------- -------� �----------------- - ------------------ ----- - --------- PERMIT No.__-6.5- __------ ISSUED_----�j__-`-- Date---------- ------------- ------------ - - ------------------ ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 134 South American Street Stockton, California ES-9-21M 9-50 W=1639