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s0 <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION <br /> -- - -------------------------------------------------- <br /> Owner's Name-------,#A-ffaOb/7 ,�4 N Phone 3 Q x <br /> Address � - hw---- ------------ ---------------------------------------------- <br /> Cantractor's Name 1'- L------'�----- -S xlr -,.---- C G I IJ Phone <br /> Installation will serve: Residence & Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f ' <br /> O<1 <br /> Number of living units: A Number of bedrooms UQ Number of baths ❑ Lot size-------- aG d v <br /> ----------------------------------------- <br /> Water Supply: Public system ❑ Community system ❑` Private, <br /> Character of soil to a depth of 3 feet:- Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam p ClayZ Adobe-q Hardpan ❑ j <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool,permitted if PU61i sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well Distance from foundation--------------------Material <br /> __________________-______--____________-________. <br /> tl j5K6-re&To. of compartments-------------------------Capacity-----------------------Size-------------------------------Liquid depth---------------------- �JU� <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material-__________------_.________________- <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- <br /> Privy: Distance from nearest well________________________________________________Distance from nearest building____--------_________________________ <br /> ❑ Distance to nearest lot line____________ _-- - __-_ <br /> ------------- <br /> Seepage Pit: Distance to nearest well--------?r-- -Distance&rom foundation--------------------Distance to nearest lot lin <br /> Number of pits------1--------------Lining <br /> material... t-lC,__--Size: Diamete r_____ '_=_b'_�.--.Depth___ -D-Q <br /> - <br /> Disposal_Field: _4.Distance-from-nearesf;=well_________________.Distance-fro.m�foundation_____-.-..______.__-Distance_to nearest lot line 5 <br /> ❑ ek Is ri Number of lines----------------------------------Length of each line------------------------------Width of trench----------------------------------- <br /> Ty pe of filter material___________________,_____Depth oflter material----------------------- <br /> Remodeling and/or repairing (describe)----------- ---fl e h_ __ - ---------------------------------------------------------------------------------•--------------- j <br /> ------•-------------------------=---------------------------- ---------------------------------------------------------------------------------------------------------=---------•------------------------------- <br /> ----------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> (Signed) ---------------------------------------r -------(Owner and/.9r_Contractor) ' <br /> By----•-----------------------------------------------•-------------------------------------------------------------------------------(Title)-------------------------------------------------:------- <br /> ----------------------------------- ---------------- ) <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must Ke—filed with this application). { <br /> FOR DEPARTMENT USE ONLY- ) <br /> APPLICATION ACCEPTED BY- - ` �' �a a O <br /> ----------------------- DATE----- <br /> REVIEWED BY------------- `/ `.°D.FG'------------------`----------- --------------------------------- DATE---- <br /> BUILDING PERMIT ISSUED-------------------F�1.0-r-�_rJC�f3?----------------•' <br /> ------------ - ------------- DATE-------------------------=------------------- ---�-------- <br /> Alterations and/or recommendations---------------------------- <br /> -----------•-----------------------•--------- -------------- cr <br /> - ----- ----- ------------------------------------------------------- <br /> ------------------- <br /> - ------------ <br /> ------------------------------------•------- -------------------------------------------------------------I-.--------------------------------=------------- <br /> ----------------- <br /> _--____»_______________________________________--_____._ _- _ . -----------------------------------------------..------------------------------..__.---------------------------------------------------- <br /> -------------------------------------------------------------------------------_______________________________________________________________________________________'_____________-___-___-_______________________________ <br /> PERMIT No...........-------------- ISSUED-_ _ '- -/ -`c �' (Date) FINAL INSPECTION BY: <br /> Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> 130 South American Street <br /> Stockton, California v c— <br /> ES-9--•2M 9-50 W=1639 .- I <br />