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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health Disfirict for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. a I------`-1----'1yo.�......,"' --------------------------------------- JOB ADDRESS AND LOCATION----------- _ _ � ---- �-------- - -- ----- --- --------- Owner's Name-------- ----------------�-'=-�--•--�-- -- - - - Address ---------------------------------------------------------------------------------------------------- ----------- - ----=— Contractor's Name- R I'. _ - �X"t. 4 '"+----------------------------------- Phone -��---a Installation will serve: Residence I] Apartment House ❑ Commercial ❑ Trailer Court E] Motel .❑ Other Number of living units: ❑, Number of bedrooms E] Number.of baths F] L-&a_ G `d�------------- •"--'- �3 I Water Supply: Public system❑ Community`system ❑ Private' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam E] Clay Loam E] Clay E] Adobe Hardpan ❑ Y 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-----------_------ ---------------------I- Number E1 No. of compartm.ents-------------------------Capacity-------- --------------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 ____-----------_--_-_----Distance to nearest lot line------------------------------------------------- Ar -------------------------------------_:--_--- .1 �0---------.Distan�:q to nearest lot line------Seepage Pit: Distance to nearest well-: -_ -______Distance from foundation__--_--.of pits_-----_1----- ------Lining niaterial_� 55 _Qmk CSize: Diameter_-.�-3---- .----.Depth---- - ------- -------- 1 '._Disposal Field: Distance from nearest well__�� _--;Distance from foundation-Ar------Distance to nearest lot lin Number of lines-------------'� -__ __---Length of each line------�--L7_'---��---.-.Width of trench---___ __ __-----__------- Type of filter ---_Depth of filter material----_l ________-- -Remodeling and/or repairing (describe):--- ----------------------------------- - -------- ----- ---------- ---t - �--=--- '----------- -- --------------------------------------------------- 1 ----------------------------------------------- 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--Ful s and regulations oft a oaquin Local Health District. (Signed)4 Signed) 1 A- ---- Wit` ---- ----- {� Contractor) /Sy:- ------ �. - %_ - ------ (Title) [Plot plans, sh w g si3e-of_l--t jacation of system in relation to wells, buildings, etc., must be fi�d with this application). FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY--------------------------------- ----------------------------- DATE------------ , d -� -------------------- 3 � REVIEWEDBY------------------------------ - - ----- ---------------- ----------------- DATE--------- ------------------------------- ----------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ Alterationsand/or recommendations------------------------- -------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ ---------------------------------------------------------------------------------------------------------------------------- --------- ------------------------------------------- ----------------------- ----------- --- ------------------------------------------------------------------------------------------------------------- ------ ISSUED--=--- ---(Date) FINAL INSPECTION BY:------ -- .-- `3 3 0 - ------------------------------------------- PERMIT No.-(t--q(-7- _-_ / Date---------------- " -------------------------- ----- t s SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639