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a. I 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. 549. Q. 4=7E ,' �-�. �`- M!�✓ �. JOB ADDRESS AND LOCATION-x--------------- �---------_----------------_--_---- - l �{3- 37�--CGa - - ------------------- - - - - - ----------------------------------------------- /�X— o L/Ii�/t.••� S [/ ----------------- Phone--- Owner's Name -- ------- . -- (� /A-Z- /cggl /y/Al le- Address •------�j ------� ----- f ----------------•-------------------------------------------------------------------------------- Contractor's Name---------------------------- '� ,------Z) R��T �G r Phone_��Z F7-------- --------------------------------------------------------------:--------------------------- Phone__��7-F_7-------- Installation -------------=--------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trail.er Court ❑ Motel ❑ Other EK Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size--_-____4�____-____�_3 ____________________ Water Supply: Public system Community system ❑ " Private e Character of soil to a depth of3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [Hardpan a 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__1S__i__-_Distance fro foundation_!______.Material___ ____________________________�__--___ �- o 3 �X /-o.G No. of compartments---------------=--=----- Capacity-------------------- - Size-------------------------------=Liquid depth-- -- ----------- Cesspool: Distance from nearest well-----------------Distance from foundation____-____________.Lining material_-------____-______._________.______- ❑ Size: Diameter----------------- '------Depth----------------------------------------------------- 'Privy: --------- ----------------------------- 'Privy: Distance from nearest well______________________________________________Distance from nearest building______________,__________________________. ❑ Distance to nearest lot line------------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------.-----------Distance to nearest lot line__________--_____ ❑ Number of pits----------------------Lining material----------------------Size: Diameter------------------------Depth--------------------------------- f -Dispos Field: Distance from nearest well____ _P.____._-Distance from foundation_____`.-_______Distance to nearest lot line___:________ [✓ Number of lines______,___:____//��__�____ __._Length of each line_____-__�0 _________ __.Width of trench____�__________________________ ` Type of filter material_____( - Depth of filter material--------opt/-'__ 3 Remodelingand/or repairing (describe):-------------- ------------- •------------------------------------------------------------------- -----------------------------•-------------------- ,. ti ------------------------------------I---------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San J6aquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed}--- ---------------• --------�10+, - -- --------- -- {Owner and/or Contractor] BY� �`" -�- d!` �-- ---------------------------------( ) Title (Plot plans, showi�9a size of location of system in relation to Is, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY <� DATE REVIEWEDBY------------------------------- ---------- --�----�---lxs--- - -------------------------- DATE---------�-_.__ ------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------•---------------------------------------- DATE------------------------------------------------------------- h -Alterations and/or recommendations--------------------------------------- -------- -------------------------------------------------------------------------------------------------------------- ---------------------------------•------------•----=-------------- ----------------------•------------------------------------------------------------•----------------------------------------------------------------------- ------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------••----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ -------- ----------------------------------------------------------- - PERMIT No.__-_-1 ------------ ISSUED---�_<__ -' - ----------------(Date) FINAL INSPECTION BY:----- ---------/__"_----: Y----------------------- Date__ -------- -tel SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 4-50 W-1639 �