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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. 54). JOB ADDRESS <! D OCA,ION._- Z/ /' .- =' ---- ------------------------------------------------------------------- LlOwner's Name---! '�_�.....`.. -----. �,GG1,*,------------------------------------------------------------- Phone--=;�_?_^ ��' �r C7 Address------ :!..fr"�` rtl.s' = ----------------------------------------------------------------------------------------------------------- Contractor's Name____ r_. d �—�.—� Phone__. .-__ �_ _ '----------- --------- -------------------------------------- Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other [] Number of livingunits: .0 Number of bedrooms :___ _ Number of baths 0 Lot size-_- _�^_ ' x 2 I Water Supply: Public system X Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe K Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:`- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material__________________________.______-____---------. No. of compartments--------------------------Caacit -----------------------Size--------------------------------Liquid depth-------------------------- 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 a Pit:- Distance to nearest well,-,4_4-_^-_,�_.__Distance from foundation____... Distance to nearest lot line-___..11- p 9 , _�� Depth--------- ---------- ----- Number of its...__,__1_________Linin material_��___� *r_Size: Diameter _ _- Disposal Field: Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench---------------------------- ---- Type.of filter material-------------------------Depth of filter material-_----___-___________ Remodelingand/orrepairing (describe)--------------------------------------------------------------------------------------------------------------------------------•------------------------ ------------------------------------- -----------------------------------------------------s----------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------=-------------------------------------------------------------------------------------------------- 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)---- J- ,j 4�'d/or Contractor) B --- �---- - - - --- --- --- --Y (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---y- 24'�r , '��U REVIEWEDBY------•--------------------------------------------------------------------------- --------------------------------- DATE---------h_4 Z"f-- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations--------------------------- -------------------- -------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------- -----------------------------------------------------------------------•-•------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- ------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------- PERMIT No.j_p_Y---------- ISSUED----Ll--- - - - -----------(Date) FINAL INSPECTION BY:-------�j Y- ------------------------------------- Date r_/—___.3 U Ca - -- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639