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S ; APPLICATION FOR SANITATION PERMIT i (Complete in Duplicate) f 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 fiade in compliance with Courcy Ordinance No. 549. 5 j i JOB ADDRESS AND LOCATION------qJ?� 5=------- V_ -.e-t---- °"q-/v----------------------------------------------------------------------•-------- 1 Owner's Name------- 3-MLI- -- Phone------ 1f Address--------� '----- N g -E� Contractor's Name......10-w- r) ---------------- _ Phone----------------------------- --- Installation will serve: Residence ['Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .m Number of bedrooms m Number of baths F1 Lot size----- d_____ ------ - _ ________________ Water Supply: Public system [-] Community system ❑ Private Character of soil to a depth of 3 feet: : Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe H--"Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) Septic Tank: Distance from nearest well________________Distance from foundation--------------------Material_______-__-_______________________________-___-- El No. of com artments_________________ ___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------LJO-_____Distance from foundation____ __ __---.Distance to nearest lot line___-_-�__-_-__ ❑ Number of pits_______:/----------- material_- =f ._:__size: Diameter-4_�_ •ul_" Depth--------l.-__�_____________ r ' Disposal Field: —D.istance.from nearest well________________Distance-from:foundafion,___y____:-_=Distance to nearesf lof-line2,n _.. ❑ Number of lines-----------------------------------'Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth .of filter material----------------------- L ________________:_:_=t ) Remodeling and/or repairing (describe):----------IV_4Z_W _--__ --------- A_01tr-------- _! __ -Lt- jl' ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- =---= ---------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinancSate laws, and rules alndeg lations of the San Joaquin Local Health District. 1 IPA- �t --- - (Signed)__-.'0: = ------k_ ` ----------------------------------------------------------------------{Owner and/or Contractor) 4 B . - ------------------------------ ------------------------------------------ ----------------------------------------(Title)---------------------------------------------------------------- 4 (Plot plans, showing size of lot,'location of system in relation to wells, buildings, etc., must be filed with this application). E FOR DEPARTMENT USE ONLY APPLICATION ACC EP ED ____ ____ , - - ---- -"�"- ----------- DATE-- --��)--�--�-�'--�--�------------ EJ ----- - -•------- - ---- ----- REVIEWED BY------- ----------------------------------- DATE-------/ -- --- -- ------------------� BUILDING PERMIT ISSUED---------------------------------------r-------------------=-----T---------------------------------- DATE Alterations and/or recommendations:- ------------------------------•----------•----------------------------...---------...------------------------------------------------ r ---------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------- 4 • I PERMIT No------ ___________ ISSUED-J-0-1-1---- _________(Date) FINAL INSPECTION BY:--------__ - 1 Date------------ , SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639