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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 -©CATION---- -- —----. --- - ^'ice---- ------------------------------------------------------------------------------ Owner's ------------------- -- Owner s Name--- __-�-�� '�___� _-__- Phone__ .__-��__�__�-------- Address �_._ --------------- - - -- --------------------------------------------------------------------------- - - Address `2— -- ---- -� ---------------------------------------------------------------------------- •---- ----------------------------- ---------•---------- Contractor's Name------ _ G.O✓in_,ti: - -`�n- ------------------------------------------------------------------ Phone_P-- cS"`4--- ----- ._.. i Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:) Number of bedrooms Number of baths $ Lot size__ ___f_ _f___________________________ Wafer Supply: Public system , Community system ❑ Private E] Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe Hardpan F-1 �J TYPE OF INSTALLATION AND SPECIFICATIONS: Q , (No septic tank or cesspool permitted if public sewer is available within 200 feet!.) ]V Septic Tank: Distance from nearest well_____ _________Distance from foundation______?_~----.Material--- C _________-_-___.__ 3 No. of compartments---------;Z—----------Capacity-----ROF-0--------Size]--"_L-j4......!%,n,.--Liquid depth___Ji.Z.-.________ 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 line------------------------------------------------ - Seepa ePit: Distance to nearest well___—�-._ ___Distance from foundation_____��_r__Distance to nearest lot line---•�--------- .....-; ' Number of pits--------_/-----------Lining material_ ��+_-_Size: Diameter----3, ---_-__-_.Depth_ sr -----?'__ Disposal Field: Distance from nearest well_____ _________Distance from foundation.___-,.I--"____Distance to nearest lot line_____R_�_____ -N ❑ Number of lines---------____/---------I---------Length of each line_________x__47--_________.Width of french----------------------------------- "�, Type of filter material_____--------------------Depth of filter material______________________ Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- ------•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------• 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 Districf. (Signed) t ' 'ir�2 - L------(O�for Contractor) ,. - ---------------- - ------------------------:-- (Plot plans, showing size of lot, location.of system in relation to wells, buildings, efc., must be filed with this application). FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY------------------ -------------------------------- DATE----------- __ -- - REVIEWEDBY----------------------------------------------------------------- ----� -------------------------------- DATE.---- ---- ------ 'j BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------- i Alterations and/or recommendations----------------------------------------------------------------------------------------_--------- --------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------•---------------------------------------------------------------------------------••------------------------ ----------------------------------------------------------- ------ -----------------------------------------------------------------------------------------•----------------------------------------------------------- PERMIT No.__/_�_7____________ ISSUED----- ----------(Date) FINAL INSPECTION BY:------- --_--- _ -__ _ -- ----------------------------- Date------------------------ �' l � ` ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639