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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 A D LOCATION- ->> /1 5 --- --------------------------- --- �- Phone__ Y r Owner's Name-- ----- - - -- •- -- -- ----------- --------- ------------- - ------- ---------------------------------- ------------------------------------------------------------- Address------� ----------1d Contractor's Name----.o--.L • -- -- - s�.a `"------------------------------------- Phonl-r- 11 77-•------- + Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel. ❑ Other ❑ Number of living units: [ ] Number of bedrooms Number of baths V Lot size_____ ----------------------- Wafer Q____ ___�_ _-__________ ______Water Supply: Public system Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: _ J21. _ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation------- _ a____��_______- D, No. of compartments---------,�-----------Capacity---W6A-------SizeJ_ _ K_ * ddepth 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___________________________________________--__ Seepa a Pit: Distance to nearest Well----------------------Distance from foundation_____7Lr__,_.Distance to nearest lot line___ _ Nurr�ber of pits__'-____/_-________Lining material.' Q_ c_Size: Diameter----- _ _______.DepthD7___3'+A__- _:..:.eDispo -Field:�- Distance from-nearest•well_< :Distarrce;from-foundation==') __� _4 Disfance-fo�nearest lot-line�_�=_____ . f i Type tuber of lines-------------- Len th;hof;.each €ine_____- _ :-'..Width of trench___ ~_________________. of filter material Deptl `:bfrrfilfer. material_______�_x_�eta. - Remodelingand/or repairing (describe):----------------------.----------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------_--------'µY-----------------------•-----------------------------------------------___----=------------------------------------------------------ Y prepared- -PP T - -----------------------------------------------------------•--------------------------------------------------- -------- --------------------------------------------------------------------- -- ------- -- ` I herebycertify that I have this application arid.tha+ 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)----101A'---t —, x` ...------------------------------------------------- ---•----------= or Contractor) -----------------------------------------------------------------(Title)- --------------------- (Plot plans, showing size of lot, location of system in rela+ion to wells, buildings, etc., must be filed with this application). / FOR.DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-"-- - ---- -- -- �- -_ DATE-------- _/-- ------------------------ REVIEWI=D BY: ---------------------------------------------- -------------- DATE--- --- �`------ -------------------- - BUILDINGPERMIT ISSUED----------------------------------- -------------------------------------=--------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations--------------------------------------------------------------:----------------------------------------------------------------- --------------------------•--------------------------------------------------------------------------------------------------------------------------•-----------•----------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------�--q------- PERMIT No.__ ------------ ISSUED-------- ---------(Date) FINAL;, INSPECTION BY:----V-U----�--- ------------------ - ----------------- Date------------------I--/-- --- --- ---�-----------=--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639 k