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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin'Local Health District-for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No.,549. <br /> Y17-_H I, <br /> JOB ADDRESS AND'LOCATION_ ---------- �r------ <br /> -7 <br /> -------- <br /> --------------------------------------------------- Phona <br /> M 1-?4-1 - ----- --b <br /> Owner's Name-----/ 1- ---- <br /> re1v ---------- <br /> ------------------------------------ - <br /> Address__ ------- ------------------ -------------------- <br /> "�Phone !!711 <br /> Contractor's Name---- - -- ------- ------- <br /> 'I -Trailer Court E] Motel Other E] <br /> Installation will serve:-:-Residence 0 Apartment Hou8e-'o Commercia <br /> Number of living units: Nimber of bedrooms Number of baths Lot size":0140--- - ----am--------------- <br /> Water Supply: Public.system Community system- El Private <br /> X <br /> XCharacter of soil to a depth of 3 feet: E],Sand 0 Gravel Sandy Loam E] Clay Loam L] Clay E] AdobeHardpan E] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permifted if public sewer is available within 200 feet.) <br /> Septic Tank:- Dista-rice from nearest well-----------------Distance from foundation-----------------_Material---------------------------------------------- <br /> ❑ No. of'compartm6l',ts-Z,--------------------------Capacity-----------------------Size--------------------------------Liqid depth-------------------e ----- <br /> , .. , 7 <br /> Cesspool: Distance from nearesfwell-----------------Distance from foundaticrt------------------- Lining material-___________________----+- ---------- <br /> 1771 Size: Diameter---------------------------------------Depth---------------------------------------------------- <br /> Privy; "Distance'from nearest'well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> • Disfance to nearest lot lire------------do------------------------------------ <br /> Seeps e-Pif:- Distance to nearest weil/j5 7------Distance from foundation-:20______-Distance to nearest -- <br /> I ' line 0- /-___-_ <br /> ----------- <br /> c _jV!. <br /> ---- ---------- <br /> 'Numbe'r of Pif9'j7jVe----------Lining materi A__5i7e: Diamet <br /> Disposal Field: -'Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_________________ <br /> ❑ <br /> ine-------- ------- <br /> El -.,,NumUer of lines_____`--- ----------------------Length of each line-----------------------------.Width of trench--------_:--------------:.--------- ' <br /> _-De fl filler ma <br /> Type of Cter material---------------------- --De fh filter material____-_-_C /filter <br /> (descri . ... -------------------------------- <br /> 'Remodeling and/or be):-------- ------- <br /> ---- -------------------7--------------- <br /> ----------------------------------­_­----------------------------------------------------------------------------------------------- ------ <br /> -- --------------- <br /> ---------- --------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------I------------------------------------------------------------- <br /> --------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------- ------ -------------------------------------------- ----------------- <br /> I hereby certify +hat I have prepare plication and that the work will e e in accordance with San Joaquin County <br /> & I <br /> ordinances, State I and les and" r ulat on of the San Jo uin Local Healthwstrict. <br /> (Signed) --------------- ------ - -------- Owner and/ Con actor) <br /> i�_Kr------ -------- <br /> --1- Owner end/ Con 6 <br /> (Title)----------- - - .......... - ------- <br /> -------------- ... ----------- t------ <br /> ( <br /> ------- - - - - - ----------------- --------------------- ----------------- <br /> this pp Ic <br /> e�w, <br /> (Plot plan-srstwing s:ize-o lot, location of system in rely to wells, buildings, efc., must be filed wi this application]. <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY---------------------------`-- ---------------------- ------------------ DATE---------- i<f -- ----------------------- <br /> REVIEWEDBY------------------------------------------------------------------------------------ ---------:- ----------------------- DATE-------------------------/----------------------- ------------ <br /> BUILDINGPERMIT ISSUED--------------------------------` --------------------------------------------------------------- DATE------------------------------------------------------------- <br /> Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------- .. f <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------- - <br /> ------------------- <br /> -------------------------------------------------------------------------------------------------------------- <br /> '177 ------: ---------------------------------------------- <br /> 14 /----------(Dqt�), FINAL INSPECTION BY.,.-----v <br /> ..PERMIT,p -------- ISSUED-- <br /> Date------------------------- -- <br /> ----- ------ ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9:50 W-1"09 <br />