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/a3r" 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. JOB ADDRESS AND LOCATION T_ n ----- ----- `�- W-`, - Owner's Name-------------------------------- r� ------"----------------------------------- Phone---- ------- Address--------------------------------------------- ------Address--------------------------------------------- ---- ---- - -- ---------25_70-- --------------------- -------------------------------------------- Q 65 - Phone -f �' f Contractors Name �/+ / � _« Installation will serve: Residence Apartment House;KCommercial [:] Trailer Court E] Motel ❑ Other E]A �^ Number of living units: -ZrNumber of bedrooms Number of baths g Lot size_21Po _ -- '---------- ! Water Supply: Public system ❑ Community system ❑ Privatex I Character of soil to a depth of 3 feel: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeg 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------------------------------------------------ 1-1 No. of com artments--------------------------Capacity -------Size--------------------------------Liquid depth--------------------------. -Cesspool: Distance from nearest well------_----------Distance from foundation----------------.---Lining material______________-_----_________________ ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- earest well____________+___________________________________Distance from nearest building______________._____--_----________----_ Privy: Distance from n . D Distance to nearest lot line------------------------------------------------ s J � � Seepage Pit: Distance to nearest Weil--- iP___--------Distanc fr o u dation/_____________.Distance to nearest lot line-._____________ _Size: Diameter~0'li_----.Depth___s��. /`�___--_____ Number of pits____.--------------Lining material1�1 (� .Disposal Field: Distance from nearest well------------------Distance from foundation-------------------.Distance to nearest lot line----------------- C ❑ Number of lines_'--------------------- Length of each line------------------------------Width of trench_----------- ------------------ -- Type of filter material-------------------------Depth of filter material_---_----___-________ { "Remodeling and/or repairing (describe)--------------- ------------ ------------- -- ,p ' _- t---- ------------------ - _ -- s _ ---------------- -- - 1 _ _ � -------------------------------------------------------------j------- ------ --- - __-__ _ _ -------------------------------------- -------------- __________________.___.________ --.____________________________________________________________--__-_______________-____._______________-_------_-__________-_____________---____ I Y I hereby certify that I have this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, d rules and regulations of e a Joaquin Local Health District. (Signed)---- t' f --�13 i - `fit---- ------------------------------- {Owner a d/or Contractor) .----- --- - ------- ----------- -----------------------------------------------(Ti {Plot ns, sho Y tle} �►� / ?> Q,/ -- ocation o system relation to wells, buildings,' etc., must be filed with this application). p ai FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ----- I ----------- --- DATE--------- � . /a ----------------------- REVIEWEDBY-------------------------------------------------------------------------------- --- ---------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations------------------------------------------------------------------- --------------------------_---------------------------------------------------------------- ------------ I ----------------------------------- i ------------------------------------------------------------=--------------------------------------------------------- S ---- --- -- ---- --- ------- ---------------------------------------- -----------{---------- ---------------------------------------------------------------------� - -------- ---------------------- PERMIT No.,IQj-Ca-------- ISSUED------14 .�� ---------- FINAL __ Date- -----------------l- ` ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-54 W=1639