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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) 4 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. JOB ADDRESS__p D LOCATfON `-1 ALO---_l._7--4�''-.4-------------------------------------------------------------------------------------------------- Owner's Name. - -------------------------------------------- -- ------------------ Phone - -- - - ------ --- -- - ---- - -- - ------------------------------------------------------ 1- 1__9'2.1-----17 Address__ = ------------------------------------------------ Contractor's Name____,-_-;.:-__- --_a_ ' ±-------------- Phone--- _ - --- Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel E] Other Number of living units: ❑ Nulrnber 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: (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------------------ ------- [l Cesspool: Distance from nearest we _________________Distance from foundation------------- Lining-material-------------------------------------- ❑ Size: Diameter--------------------------------------Depth---------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building--_______-.___------_--_______------___._. ❑ Distance to nearest lot line------------------------------------------------ See Pit: Distance to nearest well____^- ----___Distance�from foundation______ ---------Distance to nearest lot line____J�__r�_p_ epa Number of pits-------/------------Lining materialvf/1. ---Size: Diameter__ �--_1--------Depth---6-P------------------- -Disposal Field: Distance from nearest well------------------Distance from foundation----------------.---Distance to nearest lot line_________---___ � ❑ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench----------------------------------- d Type of filter material_________________________Depth of filter material----------------------. ,�''� I Remodeling and/or repairing (describe):--------------------------------- --------------------------------------------- ------------------------------------------ "'--------=--------------• l ------------------------------------ -------------------------------------------------------------------------•----------------------------------------------•------------------------------------------------------------ ------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- ----- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Dis+rict. ' i (Signed)__25-4 A `` *-� a ------------ ---------- /or Contractor) By:___4-e �� "�'' ' ? '-------------------------------------------------------------- (Plot -- ------------------ (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- ar •-------------------------------------------------- DATE � // r--------------- < REVIEWEDBY----------------------------------------------- -`- --------------------------------------------- DATE---- `'- ------�- � � ----- BUILDINGPERMIT ISSUED------------------------------------- --------------- DATE------------------------------------------------------------- -Al+era#ions and/or recommendations:-------- !__�-,1 3 .- -------------------------------------------------------------------------------------------------------------------------•-------------------•--------------------------------------------•-•-------------------- - = ---------------------------------------------------------------,--- ---------------------------------------•--- ------------------------------p----------------------- -------- ------------------• ----------------------- •-- ---------------------------- ----- --- ---- ---- ------------------------.- d 6------ ISSUED----T ,/- '-/-S`�----------jDate) FINAL INSPECTION BY-------------- - - - -- PERMIT No J -- -- -------------------------------- Date- -------- -- ------------Date_ ------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California J ES--9-2M 9-50 W-1639 1 7