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i � 3 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. 5549. JOB ADDRESS AND LOION------------------- 13--2------- 1� Owner's Name--------------------- -- V- --------- 4--,e --- - Phone------------------------------------ ----------------------------------------------- ----------------------------------- Contractor's Name---------------------4 btJ �---Y- Phone Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size________________________________-_ ________________---_____- Water Supply: Public system ❑ Community system ❑ -Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i - A___- Septic T Distance from nearest well__ --Distance from founda�ytion_____l-�rt--�Material________________��_G- + �+ 91— No. of compartments----------A-----------Capacity---��,_-��.Size__�.�- -,�-��------Liquid depth------=�--------------- i. Cesspool: Distance from nearest well-----------------Distance from foundation--_-______________.Lining material------------------------------------- ❑ Size: Diameter----- -------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well---------------------- ------------ --------- ___Distance from nearest building ---------------- --------- ------------- ❑ Distance to nearest lot line_________________________---_____________--__-__ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line----------------- F1 _____-________❑ Number of pits i Lining material Size: Diameter Dept 101 A - //. 1 V______Distance to nearest lot line____ ________ Dispos �IfField: Distance from nearest well____,��______.Distance from foundation_________� � g �D-------------Width of french----------� ---------------- Numf,er of lines______________�------______Length of each line______ �. Type of filter material----IA�--1^0-�-----Depth of filter maf6rial________�_:_ , Remodeling and/or repairing (describe):---------------_- , 04- '�r. ------------------------------------- ' ---------------------------------------------------------------------- '. - -- ---------- ----- ------- - - ----- - --- - hereby certify that.j-have prepared this applica+ion 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)------ --------- ------------ ---------------------------------- ------------------------------------------(Owner and/or Contractor) ' -----(Title) Title---------------------------------------------------------- Sy:---------------------------------- ------------------------------------------------------------- -- i-ld------------- L (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 APPLICATIONACCEPTED BY-------------------------------- a -------------------- ------------------ DATE----------------------------------------------------------- REVIEWED BY------------------------ --- DATE I BUILDINGPERMIT ISSUE_ 0.----------------------------------=---------------------------------------------------------- ------ DATE------------------------------------------------------- ---- Alterations and/or recommendations-------------------------------------------------- ------------------------------------------------------------------------•------------------------------- -- Y --------------------/------------ -------------- f------ -- ---------- -- ----------------------------------------------- ---------------------------------------------------------- 2- -------- -------------------------------------------------------- ---------------------- --------------------------- -------------------------------------------------t------- ---------------------------------------------- PERMIT No.- _ -- ISSUED_.- �--- --- -- ----(Date) FINAL INSPECTION BY: __-.__�/_ ___-_ Date------------------�/F--7��-----••-------------------------•- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639