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�,- 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 ------- _ ----------- L& - -------- - �-o- � --- "-'------=--------------------------•----------------------------- Owner's Name-------'1J_I --k------( ------------------------------------------------------- Phone--- � �------ Address-------------------------�-�'�---- -`----- ------ ---- ------- ----------------------------- ---------------------- --------------------------------------------------•----------- Contractor's Name----=--------4----- r_--:-------------------------------------------------------------------------------------------- Phone----------------------------------- _ i Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other x Number of living units: .V Number ofbedrooms Number of baths Loft size_________ ___ __:__ems ______________ 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: A �� (No septic tank or cesspool permitted if public sewer'is available within 200 feet.) � / - � ] Septic Tznk: Distance from nearest wall_____!I!__�___Distance from foundation-------�_Q_____Material---- �y't�?.r-'_______________. e 7 A# E No. of compartments-------------�------Capaoity.._�_��___--Size--�p�,__�_�--__,�C�Liquid depth---------�------------- h 1 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------- - _,____ w 1 ❑ 7 Size: Diameter--------------------------------------Dep �1 Privy: Distance from nearest well_______________________________________________Distance from nearest builcl;ng----------------------------------------- t . Distance to nearest ❑ Distance to nearest well'ne________________Distance from foundation__________________.Distance to nearest lot line____________ , Seepage Pit: - - ❑ Number of pits----------------------Lining material-----------------------Size: Diameter--------'-------------Dept h--------------------------------- • Disposal-Field: Distance from nearest well_____, ____.Distance from foundation__ __________Distance to nearest lot line_ <.V._ [ Number of lines------------I________ _________ Length of each line_______ - l Width of trench______ __ ; __ a g -9--- - Type of filter material,.lx' ---•_rQ�pth of filter material________1_ ________ Remodelliiiyng��and/or repairing.describe):-------------------- ---�+''.�'•---------�� t � ------•f a__C�C__r----- _________ y____________________9_________-________________---___-_____-______._________________________-.___-_--.____-__________________________-_-__________________-__- __________________________________________________________________________________________________________________________________________________----________.______________________________________.__-_________ hereby cern that I have prepared t is application and that the work will be done in accordance with San Joaquin County ordinances, State I s, a d rulesf�nd �cful tions of the San Joaquin Local Health District. i Signed} ` iel t SII`�___------- (Owner and/or Contractor) By:----------- -------------------------- (Ti+le) ; (Plot plans, showing ize of lot, location of systek in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- - -- -- .- -- -------------------------------- DATE---- ----� - REVIEWEDBY--------------------------------------------------- ---------------------------------- DATE--=------------------------- BUILDINGPERMIT ISSUED---------------- ----- =- ---------------------------- DATE---------------------------------------------------- Alterations and/or recommendations_____________ !' *--- -' "''---- -=-•--- -'' '`-'- ' .. '1 ---- ----------------------------------- ---------------------- t/LL--------- �= ----------------------------- ----------------------------------------------------------- ------------------------------ ------------------•--------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------- ----------------------- ------------------------------ -------- --------------------------------------------------------------------- --------------------- PERMIT No_----gC ------- ISSUED_-1-A�-P ---------------(Date} FINAL INSPECTION BY:---------w---�--------------------------------------------- i -------- ------------------------------ Date------- , ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California E5-9-2M 9-50 W-1639