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APPLICATION FOR SANITATION PERMIT I (Complete in Duplicate) s 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 AND LOC T10 --------- --------- =- 40 i//1U C�U-n_I: 1 T �`+ -___-T /�. __------------- .111' Owner's Name = '--------------- — �C___ �--- --- Phone------------------------------------ Address---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Contractor's Name GCI i✓l ' ---------------- Phone-------------------------------•-- i - --- i Installation will serve: Residence ❑ Apartment House ❑" Commercial Trailer Court ❑ Motel ❑ Other ❑ +!S 1! Number of living units: e Number of bedrooms Number 6f baths ❑ Lot size---- .- -_/_3_C)----_ __- Water Supply: Public system ❑ Community system ❑ Private D ` Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay-L'n ❑ Clay ❑ Adobe [Hardpan ❑ . a TYPE OF_INSTALLATION AND SPECIFICATIONS: k (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--------------------------Capacity-----------------------Size--------------------------------Liquid depth--------------------------- Cesspool Distance from nearest well__- to-____-Distance from foundation_- - -_--_.Lining material-- -- - -__--____-. r Size: Diameter - Depth9�?� ---`-�------ G�i.. C � u`� 4zJ �r� V Privy: Distance from nearest well----------------------------- ----------------Distance'from nearest building___--___-__-_-.--_-_---___---___------_--. ❑ Distance to nearesf lot line----------------------------------------------- ti Seepage Pit: Distance to-nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits-- ------------------Lining material-----------------------Size: D1ameter------------------------Depth--------------------------------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line___--__--_-__--_ ❑ Number of lines-¢________________________________Length of each line------ of trench----------------------------------- Type of filter material-------------------------Depth of filterrtmaterial-------______-_--_-_ Remodeling and/or repairing (describe):----__ _ -----.�s�d°�'----- ----- ----------n�.C``� �---- � .�---- ��---- 9ll l__------------------ -----•---- ---`- ----- o .� +m. .¢' °�' �- n = ` ----- ;. hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, Adle,s and regulations of the San Joaquin Local Health District. . (Signed)- r-.Y!...�----------- -------- -------------------------------------------------------------------------------------------------- ( / ) Owner and/or Contractor f By:---------- ------------------------ -------------------------------------- -----------------------------------------(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-------- -- ------ ! l --------------- REVIEWED _--- REVI EW ED BY-----------------------------------------------/14 --�--------------- ------------------------------- �_ S• DATE ------------------------ BUILDING PERMIT ISSUED-----------------•----------------------------------------------------------------------------------- DATE------------•------------------- . f Alterations and/or recommendations-----------------------------------------------------------------------------------------------------------------------------------------------•-- ------------ k --------------- --------------------------------------.--------------------------------------------- ----------------------------•------------------------------------------------- --------------------------------- ----------------------------•---------•----------------------•---•----------------- ----------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------- i ------------------------------------------------.___.-.-.-----------------------------------------------------------------------------------------------------------------.._--_.-_-_----._-_-__----_--_----..-__-----_----_-- PERMIT No.._....t-f-G_--.---- ISSUED___-4X_-�- `--------------(Date) FINAL INSPECTION BY:-----_---� " _ ------ ------------------------------- Date---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-21A 4-50 W-1[639