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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 Ordinan e No. 549. 5 JOB ADDRESS AND LOCATION__45'.1_ -Z-_---6 ------ fxW-- ------------------------------------------------------- Owner's Name ____- -- __ ___ ___ -_ Phone-_X-7� __ Address--- ------------ --•--- ---------------------------------------------------- ----------•---------------------------------------------- Contractor's Name__: _ ........------------------------------- `---- -----'"' ----------t—---- ' - --- - - - Phone------------------------------- % Installation will serve: Residence Apartment House ❑t Comercial ❑ Trailer Court ❑ Mot I ❑ Other ❑ Number of living units: Number of bedrooms & Number of baths Lot size---�__f _- __ Water Supply: Public system ►Community system ❑ Private ❑ E . Character of soil to a depth of 3 feet:: Sand ❑. Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ►[Hardpan ❑ r TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200'feet.) Septi f Tank: Distance from nearest well_________________Distance from�f u ation_____f. ater• I-----________ ______ ________ _ --__-__ 1 jj Li U de th.____ No. of compartments____________ _________Capacity___ ___ _ Size �7A__ - q p t^ Cesspool: Distance from nearest well-----------------Distance from foundation --------------Lining material-_.__-______.-_______________________- ❑ Size: Diameter ----Depth.--( ` ----------- ---------------- Privy:} Distance from nearest well_____________________________j -.4_----_=__Distance from nearest building------------------------------------------ 0 Distance to nearest lot line------------------------------------------------ I p g Number of its......................Linin material-----------------------Size: Diameter--------------------.--.Depth_-- lot line__-_____________� See❑a a Pit: Distance to pits well----------------------Distance from foundation---- --------- Distance to nearest Dispos Field: Distance from nearest well------------------Distance from foundation_ 12t Distance to nearest lot ine__45_________ Number of lines___________ ___ __ _ __ __ _Length of each line__________ _19_____--_.Width of tren< -- Type of filter materia _A_�Depth of filter material----------I______,:__ 5 Remodelingand/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 nd regulations ofegan Joaquin Local Health District. (Signed(-. ,,.... - -------------------------------------------------------------------------(Owner and/or Contractor) By---------------------------------............-------------------------------------------------------------------------------------(Title)---------------------_---- --------------------------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). 4 FOR DEPARTMENT USE ONLY DATE APPLICATION ACCEPTED BY------------------- LCJ > -------------------------------------- --------------------------- REVIEWED ------------------------REVIEWED BY---------- --------------------------------------- ------------------------------------------------------ DATE--------7---104 BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------- -----------------------------------------I,--,- Alterations -------- ----- ------------------------- Alterations and/or recommendations--- ---------------------------------------------------------------------------------------.------------------------------------------------------------------- --------------------------------------------------------------------------------•------•--------------------------•-----------------------------------------------•-•--------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------- --- ------------------------------ . --------------------------------------------------------------------------,----------------------------------- PERMIT No.-L-_-_'7_(D_______ ISSUED_______ ____�__ S_. __(Date) FINAL INSPECTION BY:___._____t-,11 ----------------------------------- Date---------------- F SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9---2M 9-50 W= 639