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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 Coouu�nt�y Ordinance No. 549, JOB ADDRESS AND LOC BION.. I ' 'a.., All �'''` --------- - -�/ _ Phone-------------------- Owner's Name..-"J(►/ -------- - --- ----- -- --------------- -- -------------- ------ -- Address-----2--� -��'-------- �yv Contractor's Name- aA� =-- C `"` Phone--?3__71sr -2------- Installation will serve: Residence Apartment House E] Commercial E] Trailer Court E] Motel E] Other ❑ Number of living units: Number of bedrooms a—Number of baths 0 Lot size-Alp57.A____J__So--_I___________________-N Water Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam x Clay Loam ❑ Clay ❑ Adobe❑ 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 foundati n____. _�_____-Ma�erial._Z. ✓ _______________��___________. _011' No, of compartments_____-_-�_----------Capacity___ 0_ ize1-_7X_-j-`_,� __ DLiquid depth__________________ ✓ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-------------------------------------- El Size: Diameter--------------------------------------Depth------------------------------ Privy: Distance from ,nearest well----------------------------_--------------------Distance from nearest building----------------------------------------- ❑ 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_________________________________ _ Dispo I Field: Distance from nearest well---C _____.Distance from foundation_____��_____rDistance to nearest lot line__ 1__�______ Number of lines___________?._ _________________Length of each line------ '`�"i ---Width of trench____ .��__-'_____________ ' ` Type of filter material-1_ ____Depth of filter material-----I __�r_____ a Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------------•-----------------------------� ----------- -- ----- -- - - - ---- - - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. - (Signed)--- ---�t --- --- ----------------------------------------------- $ for Contractor By:. ltr ----------- --------- Title � -*�------------------ { ) (Plot plans, showing size of of, ovation of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ - DATE_______ __ ___ _______ REVIEWED BY.__... , --------------------------------- -'------------------------------------------------- DATE_-----------------------'-7 --------------------------- BUILDINGPERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------------------------------------------- Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------•------_---------------------------------------------------------•------- ------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ----------------------------------------- ------------------------------------------------------•-------------------------------------------------------------------------------------------------- ------------------- -------------------------------------------- r PERMIT No.__.*.��___j-------- ISSUED---r Z--- v---------(Date) FINAL INSPECTION BY:- ----- ---------------------------- ------------ -- Date------------------- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639 I