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I { I 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 incompliance wi CCU ty Ordinance No. 549. =---- ------- ----- ----1---- e ' _173 -- JOB ADDRESS AN LOCATIO • -- ------------ Phone------------------------------------ Owner s Name---- 1 Address------------ --------- �• - ��'r� � �-0 r 'o' --- - Contractor's Name..--� fit, _____ Phone__ r Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ }Other ❑ ' Number of living units: Number of bedrooms Number of baths Lot size,--- Water Supply: Public system [ Community system ❑ Privatex ` Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted.if public sewer is available within 200 feet.) � Material.. ��-e� ___yr_______�� Sep#ic Tank: Distance from nearest well,!9 - -Distance from foundation___ No. of compartments---------�-------Capacity-----rd-a---Size_- 1; ` --------Liquid depth---�-�------------- 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 e Pit: Distance to nearest weli:_e-ylen----Distance from fo dation-_--L50 _Distance to nearest lot line---/6__.-___ �_Sizei Diameter_ _� ems_____-_.De th___ R__--____. Number of pits--:-----I-----_-__--Lining matenal. �_ •�------ p .� ------------- Disposal Field: Distance from nearest well.� Distance3from foundation__1A-_-------Distance to nearest lot li'�_____�_:--:___ Number of lines'___=_ ______________ _ Length of each line----- V =_-Width of trench____` ----------------- Type of filtermaterial._[,_ i Depth of filter material_____1.�--________ Remodeling and/or repairing (describe) --------------------------------------------------- ---------------------------------------•------ --------- - it ------ ----------------- -----------------------1---------------------------------------------------------,---•---------------------------... -------------------------------- ------------- -------------------- r -- - ----------- ---- ---------------------------------------------------------------------------------------------------------------------••------•-------------------------------- ------ r 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 Joaquin Local Health District. , + C '. or Contractor (Signed)------�1: A-- �/ By----- ------ ----- ----- ------------------------------------------------------------------Title)-��----------------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). i k FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------------- - DATE--------------- REVIEWEDBY--------------------------------- -- ---------------- -------------------------------------------- DATE------------- ------- ---- - - �---------- BUILDINGPERMIT ISSUED--------L'----------------------------- ----------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- ti • It ------------------------------------------------------------------------------•------------------------------------------------------------------------------ ---- ---------------------------------------------------------------------- - PERMIT No------ -_` y-------- ISSUED--------I l--`5--------(Date) FINAL INSPECTION BY------ --- -- --------- -------- -------------------- Date------------ ------ - - ---- -- ---- ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES--9-2M 9-50 Wd639