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l APPLICATION FOR SANITATION PERMIT �P (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 . 549. ADDRESS AND ATION '17.�41_i__�� l �� ! ' --' -- r--------------- JOB7 Owner's Name ,0—/—�- ------ � �� --------------------------- Phone--- ---"------------------ Address--------- -..__ --------- 1 � �� `�rfM Contractors Name---- --------P-6_-g=-g-(.5 (r/V � Phone "` V:1 --e;? , Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel E] Other ❑ Number of living units: .ql Number of bedrooms Number of baths I Lot size___!�� j__f_��_�_____________________ Water Supply: Public system jx 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: �1 (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material_______________._.___--_--------_____._______-_. ❑ No. of compartments--------------------------Capacity-----------------------Size--------------------------------Liquid depth--------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- F-1 Size: Diameter--------------------------------------Depth--------- -------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------------------------____-___-- ❑ Distance to nearest lot line----------------------------- _ -. _,. , ------------------ - Pit: Distance to neatest weII!!rA/Q__ 77__DisfanceZ41,-_<,0C m fo dation------�-- --__.Distance to nearest lot line----------------- Number of pitsi��'LA- -__Lining material-_- 4S.c(% i_Size: Diameter___ -- _.Depth__ ' ~" -.-Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line________________ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench-----__--------------------------- Type of filter material______ ______________Depth:of filter material ---______________-__- 1 r ,� -Remodeling and/or repairing (describe):_______ __ s -------- f.��t_ -____-,•�i'� ��. ,(.,� : r - ---------------------I--------- ------•-- 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 an gulations of the San :ceain Local Health District. # t(Signed) E ` '' ` � 1-- (Owner aZd1_ontractor) l ------- 1 tea BY� r-1, f = „- -ij---- {Title)--------- ' - -- .fit- ------------ (Plot plans, showing size of lot, location of system in'relatid to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--C------- - ------- ------------------------------- DATE_--J --_ REVIEWEDBY-------------------------------- ---z---------------- ---- ------------------------------------------..-------------- _. DATE_ — - -------------- ------ --------------------- $UILDING PERMIT ISSUED---------- - -------------------------------------------------------------------------------- DATE---------- -- ------------------------------------------ Alterations ----------- ---- ------------------- Alterationsand/or recommendations:_'------------------------------------------------------------------------------------------------------ ---------------------------------------- ----------------------------------------------------------------------------------------------------------------------=------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------•-------------'-------------- --------------------------------- - --------- (Date)---------------------------------------------------------------•--------------------------------- ------------•- ----------------------------------- - PERMIT No��,- �__-_- ISSUED-!---___-- ---y J__- _-- e) FINAL INSPECTION BY:--- ----41-. ------------------------------------ Date ----------------------------------- Date-------161f I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639