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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 AND6 LOCATION_________ ---- d ------10 _4t,4-------------------------------------------------------------------------------- Owner's Name-----•------- 14-f} S--�-----•--- '-- ------------------------------------------------ Phone--- J-_ Address------ �------- ----------------------------------------------------•------------------------------ -------------_--S----------d---- ---- -C' ------------------------------------------------------------- Phone--/----------------------------- Contractor's Name-------- ---- - ---- ------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units': ❑ Number of bedrooms ❑ Number of baths ❑ Lot size______________________________________________________________ Water Supply: Public system ❑ Community system ❑ Private Q Character of soil to a depth of 3 feet: ' Sand E] Gravel I-] Sandy LoClay Loam ElClay ❑ A -HardpanTYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well___a�_v___Distance from foundation____________________Maters______ _�_D�� No. of compartments------_---- — .......Capacity----Q!'f ......Size. _X__�_ ----Liquid depth-------_'�l� Cesspool: Distance from. nearest well__---________-_ Distance from foundation__________________.Lining material__________-_______________-__-_______. Size: Diameter--------------------------------------Depth---------------------------------------------------- _-__Distance from nearest buildin ------------------- Privy: Distance'from nearest we{I- - --------------- -------------- ------ g---------------- ------ 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------------------- ------ r'-K-^~Dis os IYField:-�- Distance from nearest well-___--� -O__-.Distance from foundation__ Distance-.to nearest_lofi.line___,_` �'�_�� f� y� Len th of each Brie_=____� __-""'---`-'V+�idth-of`t�ench-___` `:--:Jr-�""" Number of lines-----------�------------------ g . T` Type of filter material_I_� _—�_ epth of filter material---------1 xc-------- Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------------'------------------'---------------- --------------------------------------- ------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ( 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sate laws, andrules and regulations of the San Joaquin Local Health District. (Sign `Z ` -----_________________(Owner and/or Contractor] ------------------------------------------------------------- --- (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 APPLICATIONACCEPTED BY---------------------------------- --- ------------- DATE--------------------------------------------------- ------ .: REVIEWED BY------------------------------------ --------------------------------------- --- - --------------------------------- DATE----------------------------------------------------------- - BUILDINGPERMIT ISSUED--------------------------------------------------------------- ---------------- DATE------------------------------------------------------------- Alterations and/or recommendations----------------------------------- -----------•-------------------------------- ------------- " -;--------------------- --- ---- ------------ ------- -- ----------------- � - �, --- - ----- -------•--------- -------------------------- . J = - -------- ------------- --------------------- PERMIT No. ------------ jISSUED__ "_� -_1_`I_T_P (Date) FINAL INSPECTION BY: Date---------------------------------------------------••--------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES--9-2M 9.5Q W-1639