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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) "s 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. J_ JOB ADDRESS AND LOCATION- --------- -003---------- '------ ----------- �t°�� ` � �' =----------------------------------------------------------- Owner's Name--------------- Chgy��-- -��1f Phone - i Address------------------------------------------ 1�0-7------------- -t -a'-A---------------------------------------------------------------------------------------------------------------------- Contractor's Name-- N--------- W----- -------------------------------- Phone----jS --S`--T------------ Installation - will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other I_ ' Number of living units: [ Number of bedrooms 0 Number of baths Ell Lot size -------- 0.0-r __143________________________-_ Water Supply: Public system [❑ Community system ❑ Private' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam J4 Clay ❑ Adobe ❑ Hardpan ❑ ) V TYPE OF INSTALLATION AND SPECIFICATIONS: x (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_____ 5'Q_____ Distance from foundation ------- /__V ------ Material------------- ---------- No. of compartment s --------- .2- ------------ Capacitv-----9_Qd-------- Size___RX--- _�'_.5____Liquid depth________ r-2 ............ -Cesspool: Distance from nearest well ----------------- Distance from foundation ------------------- .Lining material _________---_________________-_______ ❑ Size: Diameter -------------------------------------- Depth ---------------------------------------------------- r' ,-"Privy: Distance from nearest well ---------- -------------------------------------Distance from nearest building ------------------------------------------ El Distance to nearest lot line ------------------------------------------------ I Seepage Pit: Distance to nearest well ---------------------- Distance from foundation -------------------- Distance to nearest lot line ----------------- Number ___________ _Number of pits ---I ------------------- Lining material ----------------------- Size: Diameter --------------- •-------- Depth -_-----_-------------------__---_ Dis osal Field: Distance from nearest well ��U____ Distance from foundation___ e q_.______Distance to nearest lot line_______ F Number of lines! .-_____3___ _��_____ Length of each line_S_o_•f�_trench g -----.Width of ------Z - =t- i .. h Type of filter material ----- 1�?-_--rt�i�t__Depth of filter material ______'��_-_______ -Remodeling and/or repairing (describe)-----------------------111_____""r°��----------------------------------------------------------- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -------------------- 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)---------- �J!-.x --s�-------' __�_�--------------------------------------------------------------------(Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------(Title)--------------------------------------- ------------------------ (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 -------------------------------------------- - - -------------------------------------- DATE------ _- � -- -- REVIEWED BY--------------------------------------- -------------------------------------- ------------------------------------ DATE -------------------------- BUILDINGPERMIT ISSUED ---------------------------------------- -------------------------------------------------------------- DATE ------------------------------------------------------------- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------- - - ------------------- --------------------------------------------------------------'------------------------------------------------ ---------------------------------------------------•----------------------------------------------------------- I ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------- - ----------------------------------------------------------------------------------------------------- PERMITJj� •-- ---------(Date) FINAL INSPECTION BY:---. --------------------------� Date--------------- ------------------------------------------- SAN ---------------------------------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES -9-2M 9-50 W=1639 I.