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APPLICATION FOR SANITATION -PERMIT r ? (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health District for a permifto`construct and install the work herein described. I This application is made in compliance with County Ordinance No. 549. ; JOB ADDRESS AND LOCATION_f_ �t A_Y4N�`-� - l�Q '� {-- f--I'd--- nr-N .- - Owner's Name - r---------------------------------------=-- --------- ------------------------------------ Phone------------------------------------ Address-----__------------------------ -------------------- --- -- Address-----------------------•----------- CSL- -- ` } - 1 Contractors Name t ----------- Phone--------•-------------------------- Installation will serve:—Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms (3 Number of baths [P Lot size________________8__ Water Supply: Public system ❑ Community system ❑ Private -� Character of soil to a depth of 3 feet: Sand p 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.) F Septic Tank: Distance from nearest weil------5__-- -----Distance from foundation----....t ----.Material------------ _ y _ No. of compartments------------- ----------Capacity----I O__------Size---� -�� -------Liquid depth_____l ' -..-- 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 Pit: Distance to nearest well----------------------Distance from foun'dation-------------------.Distance to nearest lot line----- ❑0 Number of pits----------------------Lining material----------------_-----Size: Diameter------------------------Depth---------__--------,------------- ? — : —Disposal;Field-w— Distance-from nearest well ; PP! Distance from.foundation_:-== 5_:-__'Distance'tornda'rest`Io"tfl ------S 7 r Number of lines____________ Length of each line_ aSof S e 5 ----.Width of trench---------*--- ------ 9 ---------------- i Type of filter material_______1_�� ----------------- --------Depth Depth of filter material--------1 fi n ' r 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. 1 [Signed)__ ---k-- - --t --.�1 J�• ) --------------------(Owner and/or Contractor) By: v/ -�J--------------•---------------(Title) =_= (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed wifh this application). i FOR DEPARTMENT USE ONLY APPLICAT• { REVIEWED BY__ACCEPTED BY----------------------------- j -DATE / - BUILDING PERMIT ISSUED----------------------------•-•------------------------------------------ ------------------------ DATE Alterations and/or recommendations_______________________ ------------------------------- ------------- ------------------------------- ----------------------------- --------------------------------------------•------------------------- --------------- PERMIT No.1f,;,---¢--I--------- ISSUED--------�p__-1'_�--------(Da+e) FINAL INSPECTION BY:------- ------------�--,� I-------------- Date - ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT J 130 South American Street f Stockton, California ES--9-2M9-50 W=1b34 !