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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. w This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_______ Owner's Name--------- Phone : _" - Address = - l Q 7 O � - ------_-"-- -------- --- ---- - Contractor's Name---4 _M ____________ --------------------"-------------------------------------------------- ------ ------------------- ------------- Phone- ------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of living units: ❑ i Number of bedrooms.] Number of baths [ Lot size___ '€ _ �'___________________________ -------------- Waier Supply: Public system ❑ . Community system 0; 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 fee+.) Septic Tank: Distance from dearest well ---If Z p tan a from foundation_� ___ t*__.MateriaL " s` ! ---_ ; - p ------Capacity .-_ r;T'cSize- #-----------------Liquid depth_ _ �+ No. of compartment Cesspool: Distance from nearest well-----------------Distance from foundation--------------.------Lining material___________---"-____ ElSize: Diameter------------------'------------------Depth----------------------- : ---------------------------- ] Privy: Distance from nearest well--------------------------------------------------DTistance from nearest building--------------------------------- ElDistance to nearest lot line________________________________________________ t Seepage Pit: Distance to nearest well----------------------Distance from foundation___________________Distance to nearest lot line___.___________ ❑ Number of pits----------- ------Lining material-----------------------Sizer Diameter------------------""__-.Depth--------------------------------- I ----------___-- isposal Field: Distance from nearest weJ19-_ t_o.Distance..frorn.foundatrior��_ _�_� Distance to nearest lot line_5___ft.-- ❑. - Number of lines----------- -------------- -----Length of`�each line_+5d0,Vv1-Width of-french--------Z-'-----------_-- t _ Type of filter material_Z��T _____Depth`of filter material----J�P. _' ....... ¢ Remodeling and/or.repairing (describe):.-__a______________-------------------------------------------------------------------------------------------------------------- --------------••------------------------•---------------------------------------------------"---------------I------------------------------------------ -+----------------------------- -------------- --------------- -------------------------------------- ------------------------------ -------------- ----------- -------------------------------------------------------------------- ------------------------------------------=----------------------------=----------------------------•-------------•-------------- I hereby certify that I have,prepar'ed this application and that the work will be done in accordance with San Joaquin County ordinances,.State laws, ules and reguEalions of he an Joaquin L qI ealth District. (Signed)------------=------ ----•--------- - -- -- ` - -- --------------------------- (Owner a � Contractor) By__ ;:. 5. (Title) n or C +or • _(Title)----------------------------- ---- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be fled with this application). 1 ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----11__ _ DATE Y�` �! ------------------------------------------- R EV I EW ED BY = ,.-k/--- --- = = =-------------------- DATE------/,e!7-_�Z ` ( BUILDING PERMIT ISSUED------------------- ------------------------- DATE Alterations -------------------------------------------------------- ---------------------- ------------------------ Alterations and/or recommendations:__ ------------------------ ----------------------------------------------------------'-------------------------------------- •---- -------------•------------------------------------------•----------- I PERMIT No.-/Q---6- .________ ISSUED_------4-/r`- '_?� _______(Date) --------------------------------------- --------------- ------ ------------------------------- -------------------------------- FINAL INSPECTION BY-------I- - Y�z� i'i7 ----------------------------- Date--------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California �. ES--9--2M .9=50 .W=1639 -