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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. S49. JOB ADDRESSLOCATION__,OZOOZI------0------ � �------------------------------------------------------- Owner's Name-- Q - ------ !- ----------------------------------------- Phone-------- ------------ Address = '--- ----------------------------------------------------------------------- -------------------- ----- c Contractor's Name '"1. .-------------------------------------- Phone '"' ,e'O_ - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ " Number of living units: Z Number of bed-rooms 2Number of baths 0 Lot size-----J" !T__ D____�_..�_ P -------------------------- Water _ --______________________Water Supply: Public system Community system ❑ Private ❑ 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.) Septic Tank: Distance from nearest well__!- ...------Distance from foundation_____ ----- Material I____ __----- ---R�____---- No, of compartments---..---_ '--__________Capacity______{122---v--__Size__ae _.__ _R__.Liquid depth---a:�Z______________- Cesspool: Distance from nearest well--------------___Distance from foundation--------------------Lining material--------------------_-__--_-___-_____. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------_----- `Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------_----_-______________________- , ❑ Distance to nearest lot line------------------------------------------------ Seepage ________________________________________ __Seepage Pit: Distance to nearest well----_ -------Distance rom f dation__._®_�.-_Distaes to nearest lot line____ ______ Number of pits--------/__________Lining material-iM---�2_u __Size: Diameter____��__________-Depth----_� ,0_!________________ _Disposal Field: Distance from nearest well_ _____.Distance from foundation___1_0----------Distance to nearest lot line_____�� f Number of lines--------------If-re__________Length of each line_____ _ ____e Width of trench_____ __-------------------- Type --______________Type of filter mal erial___ ------ -Depth of filter.material___._-- -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 County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. � '" � .�aed�/"e+r Contractor) (Signed) ru - ---------------------------- -----a BY = QN -------------------------------------------------------------------------------(Title)--- = -- -------------------------- (Plot plans, showing size of lot, location of --- --- --system in relation to wells, buildings, etc., must be filed with this application). TR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ----- --------------------------------------•-------------------- DATE--------------.--- Z�------------- REVIEWEDBY-------------------------------------------------------------------------------------- --------------------------------------• DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------- ----------- DATE Alterations and/or recommendations------------------------------------------------------------------------------------------------------------------------------ ------------------------------- k -------------------------------------------------------------------------------------------------- - - ----------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- PERMIT No------� 5�'�4------ ISSUED--- ---------------(Date) FINAL INSPECTION BY:---------- -------------------------- — i Date---------------------- ----� j� --------_----- + SAN JOAQUIN LOCAL HEALTH DISTRICT ( 130 South American Street Stockton, California Es-9-2M 9-50 W=1639