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Z . .rt_ h APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) i This pplicafions hereby madeadein cto om h ante Joawithquin Local Health District for a permit to construct and install the work herein described. application JOB ADDRESS AND OCATION---__ Phone-- _-- - ----- --- - - ----- 11-41--------------------------------------- - Owner s Name_._:: _ ___� � - --------------------- Address ------------------------------------------------------------------------------------------------- -- —---------------------- - Contractor's Nam �--- ------ � Commercial'-[] r Installation will serve: Residence A artment House F1Commercial`sTrailer Court [I- -Motel ❑ Other E] Number of living units: Number of bedrooms I-Number of baths 0 Lot size______ ________ Water Supply: Public system Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand E] Gravel E] ' Sandy Loam ❑ Clay Loam ❑ Clay [IAdobe Hardpan ❑ ` TYP_E*OF INSTALLATION AND'SPECIFICATO t (No septic tank or cesspool permitted i# public sewer is available within 200 feet.] P P P � Septic Tank: Distance from nearest well-----------------Distance from foundation_-___ ___.____.Material_(_ -------- ------- �- -----Ca aci _Q © Sized�.X��_�__--------------Liquid depth_ -- No. of compartments____---------------- --- - Cesspoo : E Distance from nearest well-----------------Distance from foundation__________-'_______.Lining materia_______----_________ - - �.� - •❑ N Size: Diameter--------------------------------------Depfli.-":�-----=` ----'- ---------------------------- - -------------------Distance from nearest building Priv ------ 9 -----------------------------• --------. Privy. Distance from nearest well_________________"._____ Distance to nearest ot Seea a Pit: Distance fo nearest lwell ine------------------------------------------------ Seepage ----------------Distance from-founcl,Oion-m__11 r_ _______.Distance to nearest lot line_______-_________ p 9 _ ,i" ❑ Number of pits----------------------Lining material----------------------SizeDia+�r-----------`- Depth Disposal Field: Distance from nearest well_____________"__-Distance from foundation--------------------Distance-,to nearest lot line________ _____•_ Number of lines-----------------------------------Length of each line --------------------------Width of french---------------""""- --------- ❑ Type of filter material-------------------------Depth of filter material------------------------ l -----I-2-- Remodelin and/or r pairEng ( scnb :.___----__ ../.- -- -- --- = -__ -� ____ _______ ______ ..-_____.________ r v ereby r#ify that I have prared this application and that the wo (will be dans in accordance with San Joaquin County ordinances, S ate laws,,and rules ante r. gulations of the San Joaquin.Local Health District. P-------y---- --------------------------- (Owner and or Contractor) (Signed) ---------•------------------ / BY e------------------------------------ Title .L_ {-- --------- -------- -- ------- (Plot plans, sho ing 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________ ___ " ------------------- -------- --------- DATE - ~ REVIEWED BY------------------------------------•-----------•----------------------------------------------------- - DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED----------------------- ------- ------------- DATE------------------------------------------------------------ Alterations and/or.�recommendations-------------------------------------------------------------------------------------- ----------------•--------------------- --------- ----------------------- ----------•------------------------------------------------------------------------ - . - Y _____________________________________________ •--------------------------•---------_--------------------------__C_•_ ------------------------ ---------------------_______---••___ ______-_________--___•_-______---_-______________-_______ ----_.(Date): Date FINAL INSPECTION BY:----------1 J__ --------------------------- PERMIT No�--�-F�----- ISSUED------------- ----- --- i � �^ - Date ------ r --�-� ----------- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639