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APPLICATION FOR SANITATION PERMIT 5� 7 (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_____________________ ______ _____________ �� ',�,�«_�Z ----------------------------------------------- Owner's Name-------------------------------------------------}!�� r' I /Z_L!__ ° -.--------------------------------------------- Phone------------------------ . � ---------- Address L 1 �r Address-- to-' _f _ `. j ----------------------------- Contractor's Name =1-..: ------ , ,�-R-` �--- ?`= `-� ---•------------------------- Phone---�=-�-�Q�------- �"I Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Ej / E Number of living units: ® Number of bedrooms 1, Number of baths ❑ Lot size----- -------------------------- ----------------------- 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 !1 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 ._...___________________________________________. ❑ No. of compartments-------------------------Capacity-----;O---------------Size--------------------------------Liquid depth-------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- n ___--_-______________-_- ___________❑ Size: Diameter____________________ -----_ _ Depth �----------------------------------------- Privy: Privy: Distance from nearest well----------------------__________________---------Distance from nearest building______:'_____-_-----___________________-` ` t ' ❑ Distance to nearest lot line________________________________________________ 1 Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth----------------•---------------- r Disposal Field: Distance from nearest well__y4�--F.Distance from foundation---7--____-------Distance to nearest lo} line_ ...... Number of lines__________..___T---1-----------Length 'of each line--------- = _� Wid#h offrench-------- 9__ ---- -____________ Type of filter material__-�_1___XQ----Depth of filter material-------- Remodeling and/or repairing describe :_____.�_G+` :�:.. /-------- f S ! . -------------------------•-------------------•----------------------------------------------------------------------------------------------------------•-------------------------------------------------------------------- -------------------------------------------------------------- ----------------------------------- 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 JoaquiniLocal Health District. (Signed)-------(-"--ry------ t t -' --�?_ ------ ------ ---------------------------------(Gwm.mm�df or Contractor) y: 4 ----- --------- -------------(Tale)----- (Plot plans, showing siz of lot, location of syste m relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT IUSE ONLY APPLICATION ACCEPTED BY ---------------------------------------- DATE - REVIEWEDBY------------------------------------------------------------------------------------------ -+---- --------------------------- DATE---------------------- -------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations:----------------------------------------------------- ---------------------------- ' = --------•---------------•-------•--------------------------- s --------------------------------•---------------------•------- ----------------------------------------- Iy------------------------------------------------------------------ --------••----------- 4 PERMIT No___s570 ------ ISSUED----------- - -- (Date) FINAL INSPECTION BY:---------- /-_- ---------------------- ---- �— Date 2 g -------•----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1539