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APPLICATION FOR SANITATION PERMIT �-i (Complete in Duplicate) *A, ftipplication :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. 4 JOB ADDRESS AND LOCATION---------- ---------------------------------------------------------------- Owner's Name___ Q_C41_g_f_ 7 l U--------- ---'------------� Q- ----Q-�-l----------------------- N-�- - '- --------------------------'- -'---- Phone__�_'�S_�_.�h;._:--rs--- Address------------------------------------ -Contractor's ---1 ---------9------------ F -Contractors Name--- = - - ------------------------------------------------------------------ Phone------------------------------------ ----------------------- Installation . Installation will serve: ResidenEe q'}"Apartment-House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Oki, f 'L~ Number of living unitsjq Number'of bedrooms 0 Number of baths ® Lot size______Z ____X_.___�_� Q _t= --__._ ❑ Water Supply:_ Public system, Community system R Private ❑ 4 ...d Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay El Adobe Hardpan' TYPE OF, INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) • i Septic Tank: Distance from nearest well________________Distance from foundation__________t____Material_ _ __-_____ j _-______ __ ___ r No. of compartments------___j___________ CapacitY -----Size__________-_________*_________Liquid depth ___% Cesspool: Distance from nearest well-----------------Distance from foundation--------------------LIning material----------------------------_________. ❑ Size: Diameter--------------------------------------Depth--------------------------------------=------P Privy:, Distance from nearest well-------------------------------------------------Distance from nearest building__________.-___.________________________ ❑ Distance to nearest lot line___________ 1 Seepage Pit: Distance to nearest well------- ----------Distance from fou dation__,yW---_-----Distance to nearest lot line-_.:fir_______ ' Number of pits_______ ____________Lining material - _Size: Diameter____�__�_____ _ Depth_C _ - 'Dis l Field: Distance from nearest well___^ _Distancerfrom�foundation__ C1_______:Distance=to-nearest lot } � -- gline / � ' Yp �" ---Len Length of each line- - - � ---------- ----------------------- Type -------------'-- T Number ebof filter materia____ Depth of filter material____ - p Width of trench_ Remodeling and/or repairing (describe)-------Aljg..v_--------40-A4-ra--:--------------------------------------------------------------------------------------------------- - ---------------------------------------------------------------------------------------------------------- ---- --------------------------------------------------------- ------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance.with San Joaquin Coun ordinances, State s, an///d777ules and regulations of the San J aquin Local Health Dis+rict. w ', R (Signed} :. - - ------ - ----- .. . ._--------------- ----------------- - - (Owner and/or Contractor] (Plot plans, showinze of lot ocation system in a+ron to wells, buildings, etc., must be i ed with this application P FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE ------------------- ---------------- REVIEWED BY E "`------------------ DATE--- - = $UILDING PERMIT ISSUED------------- ---------------------------- DATE-- --------- Alterations and/or recommendations:---------------------- ' _. T , --------------------------- - - PERMIT ISSUED________a_ __ ._s�s_j--_- Date FINAL INSPECTION BY:__ % ' _ _ ----------------------- / y i ------ Date----------------- ' .z----------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street _ Stockton, California ES-9-2M 9-50 W-1639 ., a