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pol 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. (r- JOB ADDRESS AND LOva,1114 IN------ /c�I t/ TL - -'1 -- � fG1U l Owner's Name ------- 4--_x�-Y--------------�=I�./�.`/ Phone -__91 � _. Address-------------------------r-'--- ' (o--�-...---- ,5 `C------t/l�a--S-id!.�--:v.--'...��.'4!-----------`----Z,..................... ................... Contractor's Name . sv ------------------------------- Phone----------------------------- ------------------•---------------- T------------------------------------------------------ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size-------------------------------------------------------------- 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: N (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_________________________---_--__----. ❑ 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 foundation--------------------Distance to nearest lot line---------------- ❑ Number of pits----------------------Lining material--------------,_-------Size: Diameter----------------------_.Depth--------.----------------_------ Disposal Field: Distance from nearest we11------ __.Distance from foundation__-_-_=_(-r_--------Distance to nearest lot line____�_____ Number of lines____________ Length of each line----- of trench-- ___ �4_`�------------- Al i Type of filter matenal__:�_____r- =Depth of filter material___--___ :�_-_____ Remodeling and/or repairing (describe :- ----- ----aY -------------a ------•-------------- --------------- ---- ------� - l 7P- --- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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. (Signed)-----K-- �`---- --------------------------------------------------------------------------------------------(Owner and/or Contractor B (Title)_ ------------------------------------------------------------------ --------------------------------------------------------------- (Plot plans, showing size of lot, location of s`y_`s?m in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------------------- DATE REVIEWED BY---------------------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------------------- ----- ----- ------------- ------ - - - -- --- ------- DATE------------------------------------------------------------- Alterations and/or recommendations------------------------------------------------------------------------------------------------------------------------------- ---- -- ------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------ ----------------------------•-------4- --------------------------------------------•-- ------------------------------------------------------------------------------------------------------ PERMIT No.-V-3---------- ISSUED---_-- ---1___ - -5'�-----------(Date} FINAL INSPECTION BY:-------W-- - ------------------•---------------- Date--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1539