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x APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) l , 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. JOBADDRESS AND LO/TION--�;�-�------------'--------- -�----------------------------------------------------------------------------------------------------- Owner's Name--------- �-f__ !_�aw—Ax------------�/` -�_ ------------------------------------------- Phone----/3-'� 7 Address = ` Contractor's Name-------------------- --- bZxJ/111<-< --- Phone------------------------------------ Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: [� Number of bedrooms [2--Number of baths ❑ Lot size-------------------------------------------------------------- Water Supply: Public system ❑ Community system ❑ Private ER'-" 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 200 feet.) ptic ank: Distance from nearest well----`�?`---.Distance fro foundation-----/P---------Material_-_-_:__-le�------------ Se ` - - . T No, of compartments---____--_--�___---Capacity...�0_0-____Size__--3_�__. ___Liquid depth----____I_ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-____----_--_-------_____--_________! ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- 'Privy: Distance from nearest well-_------------------------------------------ -Distance from nearest building------------------------------------------ El Distance to nearest lot line------------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- F Number of pits----------------------Lining material-------------.---------Size: Diameter------..---------------Depth-------------------.------------- Dispos I Field: Distance from nearest well__`7�'__---..Distance from foundation___�-----_:_____Distance to nearest lot line________________ Number of lines----__b__--____ -_40, _-____ _Length of each line-------/-/-P�----------_Width of french-----------a-kl/-------- Type of filter ma4,,ial__ __ l'�-Depth of filter materia€----__-_-- ,f4 r Remodelingand/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 laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-------------------------------- - - ------ ---- -- (Owner and/or Contractor) By:- ..................(Title)-------------------------- (Plot plans, showing size of lot, location of system in relation to wings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- ------ -------------------------------------- DATE---------- REVIEWEDBY-------------------------------------------------------------- - -------------------------------------------------------- DATE--------- BUILDING PERMIT ISSUED --------- ----------------- T /DATE Alterations and/or recommendations:--.--J_�-!G--- -=-----5 --- ?Ff--- •��Sh,Q_st,---•--- `/9_�J :--- --<--------------------------------- -------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------•-----------------------•--------------- ----------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------•----------------------------------------------- ------------------------------------------------------------------- _ ------------------------------------------- _._------------------------------------------------------------------------------------------------- qq µ PERMIT No.�E'_�------- ISSUED--- 3 �^/-----------(Date) FINAL INSPECTION BY----------------------------------------------------------------- Date-------------------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California E5-9-2M 9-50 W-1639 I