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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) r Application is hereby ade 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--__ --- --------- ---------------- ------------------- Owner's Name � ---------------------------------�-- - ---v---------------------------- Phone------------------------------------- " -F---------- ----------�``._.�--`---------------------------------------------------------------------------- Address t °........ . . 'er© Contractor's Name__.._b.T - ------------------------------------------------------------------ Phone-- -:!: Installation will serve: Residence ❑ Apartment House ❑ Commercial Trailer Court ❑ Motel ❑ Other ❑ Number of living units: E] Number of bedrooms F] Number of baths M Lot size____I_ _____ __ D_'_____________________ Water Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam C1, Clay ❑ Adobex Hardpan 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----L.2_Q---Distance from foundation____--�'__--___-__.Material------- ------- ` No. of compartments_______ -------------Capacity___�ff_��0Size__Ir__, _ CFA Liquid depth---S-4_ ...... Cesspool: Distance from nearest well____-------------Distance from foundation-------------------.Lining material____________--__-_--_--_----____---__ ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ El Distance to nearest lot ( line_____________-_____ - -- Seepage Pit: Distance nearest e1 � .»� nfr Distance to nearest lot line---/f------- 4 Nuberr of p ----- Lining material.-6-4.4 A4----Size: Di� r__- � Depth_ 7` __, p______ Disposal Field: Distance from nearest well___ Distance from foundation_____ _____Distance to nearest lot line__ __ I-------------- - Length of each lin e------moo-- ------.Width of french-----1� y-'1-------------_- '�' Number of lines___________ _ Type of filter material4--�'_------------------Depth of filter material____1_ Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------------------------------- ------ ---------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- ---------•-•------.-------------------------------- 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. [Signed)____R , (?Ovo �"''--- °''' ---------------------------------------------------�--- - ,[QW -r-i !/or Contractor) By:-----/�� --------------------=-----------------------------------------------------------------(Title) E f� Plot plans, showin size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). [ P 9 Y g � PP• )• FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------- --- ---------------------------------------------------------- DATE------- 14---- c & --------------------- REVIEWEDBY--------------------------------------------------- -------------------------------------------------------- DATE----------- ------- ------ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------------------- --_ DATE------ --------- --- ------ Alterationsand/or recommendations:--------------------------------------------------------------------------------------------- -----------------------------------•--------------------------- ------------------------------------------------------ ---------------------------------------------------------------- ------------------------------------------------------------------------------ --------------------------------------------------------------------- ---------------- ---------- --------------------------------------------------------------------------------- -----------------------------------------------------------7 -------------------•------------------------------------------------------------------------------------------------------------------ PERMIT No.._.'>U1------------- ISSUED_`'_--__.---______----__-_____________(Date) FINAL INSPECTION BY..---.------------ Date._.------; ------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W4639 639 _ a sk