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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) 4,0,- Application is hereby made to the San Joaquin Local Health District for a permit to con ruct and i st the rk herein d scribed: This application is made in compliance with County Ordinance No. 549. �-� ' � K_5 �� �• 1t JOB ADDRESS AND LLOCATION_A_t_�__r�_�___'` - -- E'�-r-o-L---�-�------`-_---- = _�_ _'- 44__ `}_!---- - ` =_ ----- /f' ��,.+ G -t`'!_ �' ----------------------------------------- Phone---`r------ --`---------------- Owner's Name----�---------------------------•=------- - -- 1-�`--t------------------ ---- ---.;----- -- Address--- �--- - _ ! E r Contractor'sNamer -a^- - �"` =- ` FI--------------------- - - ----------------------- ---------------- Phone----------------------------------- installation will serve: Residence IBJ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑r 'Number of bedrooms $ Number of baths m Lot size _�-7_l/____ _f___-� �J----------------- 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 -at---Distance from foundation_-_- 0_r.__.Material---- `(y9 No, of compartments------!---------------Capacity_r_P_0---------Size____'�_1----1�------------Liquid depth_______--------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____________________-------_-___---_ ❑ Size: Diameter----------------------------=--------Depth--------------------------------------------------- Privy: Distance from nearest well_______________ ______________________________Distance from nearest building------------------------------------------ 11 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---------------------- -------- Dispos Field: Distance from nearest well___�,__9____,Distance from.foun — - - __,_EAstance to nearest lot line_. Number of lines--------- -------------------------Length of each line___ ------ _�_____________Width of trench_�------------------------------ Type of filter matenal___R___ T_ ___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' regulatio s of the San Joaquin Local Health District. (Signed) ''' --- ---,It �-------------------------------------------------- (Owner and/or Contractor) Y By-------------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plo+ plans, showing size of lot, location of system in relation to Mlells, buildings, a+c., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BC ------- --------- DATE---------- ---�- '�� Z"------ REVIEWEDBY--------------------------------- ------------------- ----------------------------- -------------------- DATE BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:---------------------------------------------------------------------------------------------------------------- ---------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------ ------- -------------------- ----------------•--------------- PERMIT ---- ---- ---6 ISSUED ---7 --(Date) FINAL INSPECTION BY------- ------------------- -------------------- Date 5� ----�-------- -- � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9--2M 9-50 W-1639 c 1