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APPLICATION FOR k R SANITATION PERMIT y (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work heroin described. This application is made in compliance with County Ordinance)j No. 549. �• JOB ADDRESS AND LOCATION- _1.. r -- ----------------------------- --------------- Owner's Name est lDMQn ----------U ---------------- -------------- --- Phone------` --- -.--- Address �� =-------------------- Contractor's Name-=. �_._11-9111V'M-1.---------------------------------------------------------------------------- Phone ------------ Installation will serve: �Residence;Ej,, Apartment House ❑ Commercial ❑ %Trailer Court ❑ Motel ❑ Other Number of Living units: Number of bedrooms ❑ , [�] Number of baths ❑ Lot size______, , --y(,--___---1_L�_-- r Water Supply: Public system ❑ i Community system ❑ Private [ ` Character of soil to a depth of 3 feet: Sand ❑Gravel ❑' Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ] Hardpan ❑ C1` I ! j 1 TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if public sewer is available within 200 feet.) n M. om nearest wellDIstance ala -------- -------- ---------------- ---- --------------------------- co Cesspool: !Distance from nearest well-_0 from foundation___/Q_/_-"""__.Lining material__ ,B�p� Size: Diameter-----_ -� i -Depth--------=� ------------------------------ Privy: 'Distance from nearest well_______________________-I-_ - --------- ____Distance from nearest building �Disfance to nearest lot line " Seepage Pit: Distance to nearest wefi---------------------- Distance from foundation________ Distance to nearest lot line-----------___-." ❑ Number of pits-------------- -------Lining material-----------------------Size: Diameter------------------ ---.Depth --------- ---------- -------- p eld: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line-_______________ ' Number of lines----------------------------------Length of each line------------------------------Width of trench---------"- -- Type of filter material------------------- ______Depth of {filter material,--------- --------------- Remodeling and/or repairing (describe]:___________ ------P-0- r-� �.a_, -- - �,1/1-------------------------------- -------------------------- I ---------- ---------------------------------------------------------- -------------------------------------------- - - -- - - - ------ I herebycertify that I have ` Y 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)___ �,"_rZ ,� ------ ------------------------------------------------------(Owner and/or Contractor By:-------- --------------------------------------I-------------------------------- - Title / } ----------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must'be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_________- REVIEWED BY--------- - ' ------------ ----------------------------- -------- DATE------- rL ------------------------------------------------------- -------- - DATE BUILDING PERMIT ISSUED ---------------------------------------------------- _____________________________ -------------------------------- ---- DATE-------- ------------------------ Aferations and/or recommendations:_"f'----- - __"'_-_" -------------------- - -------- --------- - --- ------------- ---------------------------------------------------- ------------------------------- ---------------------------=-------------- -------------------------------------------- ----------------------------- ---------------- ------ - - - _-- PERMIT No._�5 -f---- ISSUED--- -----------------� {Date] F1NAL INSPECTION _-____.-. _ -- --------------------------------------------- Date_--- " SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W�1639 Stockton, California