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r3 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 in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION ' /1� -------- -�.rU---f� - _.------1 �/ ----------------------- - - Owner's Name_. ---------------------------------- -------------------- Address -/�---- --- //t /�.-i..�.- --------- -------- ------ Phone-------------------- " --- --------------- ------ Address --------- e� .. --------------------------- onrector s Name------------------------------------------------------------- ----------------•--------•----- - - --------------------------------------- Phone---------------------------------- --------- --------- ---------- nstallation will serve: Residence Apartment House p Commercial ❑ Trailer Court ❑ Motel ❑ Number of living units: [/ Number of bedrooms Other ❑ �' Number of baths ❑ Lot size___-___..__f��"""__/"/____ � Water Supply: Public system Community system -----------"-"----- Y ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E!� Hardpan i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se Distance from nearest well----------------- fro foundation___AQ_-_ Material._____ __---- (No __ t,4 " x u Q No, of compartments--------- .21- ------------------" , __ ------Capacity-------��--------Size �-�---- �-•=�-- - Liquid depth --- ----- - Cesspool: Distance from nearest well_____ Distance from foundat'on---/� """_.Lining material_ A0 j Size: Diameter r� ------I -----------Depth �`� - =------------------- :Privy: Distance from nearest well-______________________ Distance from nearest building--------------------------- ❑ Distance to nearest lot fine---------------------------- ------ -------- ----- Seepage Pit: Distance to nearest well_____________________ Distance from foundation__-" ------------------- Distance to nearest lot lineEl _______________ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------- f Dis os ield: Distance from nearest welly_____________ Distance from foundation---- Distance to nearest lot line_____ __-- Number .f Jrnes-_-`----> o---------- LenjUth of each line--------4B 10---- Type o filter materia4_C2 ,� 4 Width of trench__-____ ---- --_r __.-C�pth of filter material----------_��----- ------------ "Remodeling and/or repairing (describe):-_________"__________________" ------------------------ ----------------------------------------- ------------ - ___ - ------- -------------- _ --------------------------------------- I hereby certify that I have prepared this application and that tPkie work wi I be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local H Ith District. ✓ �� r. (Signed)------�-•,�- -_/ I f Y_ _____ _______ - ----------- ---------------------------------------------(Ow By:. ---------------------------------`--------------------- ----- (Owner and/or Contractor) (Plot plans, showing size of lot, location'of syste in re tion o wells, buil rugs, etc., must�be1efiled with this application). { DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ---------- DATE---------- ,� ----------------------- REVIEWED BY--------•----------------------------- -- , ---------------------- - -------------------- - -------- DATE------------ ------- - UILDING PERMIT ISSUED--- ---------------------------------------------------------- -- ----- -------- ---------------- ------- -------- -- ----------------------- --------------------- DATE------------------------------------------------------------- -1 - terations and/or recommendations:__-.'_________ _____-_" ------------------------------- -------------------- --------------------------------- ----- ----- ----- --- - PERMIT No.-__-0 ---- ISSUED_.-----i_"_ --------------------(Date) FINAL INSPECTION BY:__-_____-""-__.__"---- --------------- Date --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Es-9-2M 9-50 W-1639 Stockton, California