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APPLICATION FOR SANITATION PERMIT G 3 (Complete in Duplicate) l 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 N 49. JOB ADDRESS A D LOCATIQ Q.__,;V60 Owner's Name-- -----------•-- ----------- ------ �s �.J - ------ --- ----- ------ ---------- ---------------------------------- -- Address----------- O_ Phone------,-- Contractor's Name___ ___ __ ______ i e - ------- --------------- --- -------------------------------- --- -- ------ I installation will serve: Residence Phone-- _•-. �--'-- """""""""artmentHous Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. Number of bedrooms ( Number f baths Jt Lot size_____ Water Supply: Public system ❑ Communit system _l- PP Y� { Y y ❑ Private Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Gay Loam ❑ Ga TYPE OF INSTALLATION AND SPECIFICATIONS: Y ❑ 'adobe Xardpan ❑ (No septic tank or cesspool permitted if public sewer is available within 200 feet. Septi ank: Distance from nearest well"" �"_•- ' sem- Distance om fou ation_____ Mat ial. __ No. of compartments------------- Capaci+y�lu" Q�• � - -- ----------- �ze -- --- Liquid depth-------- -------------- Cesspool: Distance from nearest well--___------"-----Distance from foundation R___________________Lining material ___________ ❑ Size: Diameter....-- ------------------------------Depth------------------------------------------------- r = Privf00 Y� Distance from nearest well-________________-_________ Distance from nearest buildin ❑ :� Distance to nearest lot line-------------------------....................... 1 g------------------------------------------ Seepage ----- ------ -------- ----------------- Seepage Pit: Distance to nearest well______________________Distance from foundation_--_ ❑ Number of pits______________________Linin material___r__.______ Distance to nearest lot I' ---------------- Diameter--------=-------------.Depth--------------------------------- Disposal Field: Distance from-CAnearest well_C "i -__--.Distance from foundation------ --------Distance to nearest lot I e__:... --------- Type of lines- Length of each line______."'f-irk _ Type of filter material-_" "_ �" -------width of trench____ -----_--_----- �lDepth.of filter•material__________i" Remodeling and/or repairing (describe): f r. - = ---- ------• ----•--------------------•------------------------ 1 I 1 - - ----- ---- ` ------- -- -------------- t = }-i-----------------I------ --------•--•----------------------------------- hereb certify +ha+ I have----------------------------------------------------- -----------------------------P. .. ----------------- Y Y prepared this application and that +hework�will be done in accordance with San Joaquin County ordinances, State laws, and rules and' reg"Mations of the San Joaquin Local Health DisfHcf. (Signed)_. ----------------------. Plot lens showing size of - t � �1 I (Owner and/or Contractor) By:. [ ( P _ -------------------- (Title) -----------------•---------------- - lo+, location of system in : lation to.wells buildings,.etc., must be filed with this application). i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED•BY____ ------- .,. REVIEWED BY. - ------------ DATE ? r I ------------------------------ ------ DATE---------------- BUILDING PERMIT ISSUED-------------- -- --- - ---------------------- ------ - --------------------- --------------------------------------------- Alterations and/or recommendations------ --------" --------------------------- DATE------------------------------ ------------------- ----•--------• ------------------- - I -------------------------------------------------------- ---------------------------------------------------- -------------------- ---------•-- � ---------------- PERMIT No "-_"-- _-_-- ------ ISSUED. ------- �- Yp_ "� -----(Date) FINAL INSPECTION BY:------- " _-- __-_ Date -G �` �� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W=1639 Stockton, California 1