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p ' APPLICATION FOR SANITATION PERMIT f .� (Complete in Duplicate) Application is hereby made to the San Joaquin Local Heaith 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__I-_ - - '0 ��++ G- 1 Owner's Name ------ ------•------------------------•------•----------------------------------- ----------------------- ----------------------- Phone----- ----- Address- ---- --------- ---------------- � ---------------- - -------------- - ---------- --- - Contractor's ame_-•---------------•- -------------- -------------------------------- -- ----- ------------- - ------------- _______________ _ - - ------ -------------- ------. Phone-------------------------------- - nstallation will serve: Residence$ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: [V Number of bedrooms 9-- Number of baths [p Lot size------ ______ __ Water Supply: Public system ❑ Communitysystem Y ❑ Private Character of soil to a depth of 3 feet: Sand ElGravel E] Sandy Loam ❑ Clay Loam ❑ 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-- r „��___--Distance from foundation________LIQ--___.Mater _-__--_R- No• of compartments"__ �' ---�--------------CepacitY•--- _- Size---- _ --- = ` a ,X•5----Liquid depth ' Cesspool: Distance from nearest well_______________ 9 p �--�--�-"----- --- _Distance from foundation______________ ❑ Size: Diameter-------------------------- Lining material Depth from nearest well________ _______________ ______-_____-___Distance from nearest building ❑ Distance to nearest lot_.line------------------------------------ --- g-------------------•----=-�-------------- Seepage Pit: Distance to nearest wall_______________ _Distance from foundation___________________.Distance to nearest lot line__._______.______ ❑ Number of pits___________________•_Lining material__ --------------------Size: Diameter---- -----------------.Depth-------------------- ` Disposal Field: Distance from nearest well-- '(}�- Distance from foundation___ - _ Number of lines.---!-------- _ /0----------Distance to nearest tot fine__--IF_•---•-_ --------------- Type - - ------_;Length of each line---_----- i, I -- Width of french______' - of filter mat�rial__ ___ '14�_-Depth of filter material-____"__1__4-- Remodeling and/or repairing (describ ----------------- ----------------------- a1 - 1__ --------------------- --------------- _.,� _�, ------------------ -------------------------------- ---------- -------------------------------------------------------------------------- ----------------• --- ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. -------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County (Signed)__,_____ ------ ---------- i ` ------------------ ------------(Owner and/or Contractor) r BY� ------------ ---- -- L j (Plot plans, showing size of lot,tf6Cation of systeation o wells, buildings, (Title}__-___---__--,---- --------------------------- -------------- gs, a c., must be filed with this application). - � litiL FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------I__ REVIEWED BY --- ---�----Iq -------- ------------------------ DATE =*>7_.r _ _ --"'". ,� --�---------- ---- BUILDING PERMIT ISSUED-------- - -------------- DATE--------------------------- ----------- --------- DATE------------------------------ ----------------------------------- erations and/or recommendations:_---) - ----------------- _ ---------------------- ------------------ _ ------------------ --------------------W_- ---------- -------------_----- -------------- -------------- C t� 4 ------- ------------------------------------------------- r * ------------------------------ -- ------ ----------------------- -- ---------------- PERMIT No.__ -- ISSUED - -_(Date) FINAL INSPECTION BY:__________ ------_ Date -------------- - ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W-1639 Stockton, California