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i67 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. Ae L, JOB ADDRESS A D LOCATION__��r� - i — Owner's Name # s -' ` ----------- Phone-s: -55-13 , a Address ---------------- = Contractor's Name ' c - Phone__-G—$14 - ------- ---------- -- -- Installation will serve: Residence X Apartment House ❑.;Commercial_❑ `Trailer Court ❑ Motel.❑ Other ❑ ..-, Number of living units: Number of bedrooms {Nilm�-ber of baths -Lot size_____ Water Supply: Public systemKL ; Community system ❑ Private L] =* Loam � V Character of soil to a depth of 3 feet: Sand ❑ E]Gravel Sandy Loam E] Clay Loam El Clay E:1Adobe H�a�dpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: L Ilk (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Septic Tank: Distance from nearest-well--------------- ___Distance from foundation--------------------Material _______________-__,____________-__' ❑ No. of compartments--------------------------Capacity-----------------------Size-----------------------------...Liquid depth-------------------------- Cesspool- Distance from nearest well-----------___Distance from foundation--------------------_Lining,material___.__________________.- Size: Diameter--------------------------------------Depth---------------------------------------------------- - r Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_'_-_________------___:__ ----------------- Distance to nearest lot line_______________________________________----____ ^'at + Seepage Pit: Distance to nearest we/ll - "`' ------Distance,�from foun ation__ ,---_--.Distance to nearest lot line-__s:�_____.___, Number of pits__-_______!'.______Lining materiaL�r!_-_/, Size: Diameter____,, __________.Depthv' +'dl0Q-; I Disposal Field: Distance from nearest well________________Distance from foundation--------------------Distance to nearest lot fine______--.________ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of fren-ch--------------------------------- Type of filter material_________________________Depth of filter material_---________________--- 1 Remodeling and/or repairing (describe)---------------------------- -- ------------- ___-_-_---------- ---- ---- -------------------------------------•-----------•--------------------------------------- ------------------------------------------------------------------------------------------------------------------------r---- --------------------------------------- - I hereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin County ordinances, S to lid rules and' regulations of the San Joaquin Local Health District. r � (Signed)---- - ---- ---.. ®` O.den.ared r Contractor------ - ------- - ----- ----- ---- --—----------9 ) -----------------------------------------( , /o or By:--- --------------- �----------- Title -- ( } - (Plot plans, showing size of lot, lova+ion of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------------------- --------------------------------------------------------- DATE--------- REVIEWEDBY-----------------------------------------------------------------�--------------------- ------ DATE----------It 2-Z' ---BUILDING PERMIT PERMIT ISSUED----------------------------- ----------------------------------------- DATE ------------------------------------ Alterations and/or recommendations------------------------- -- ----------------------------------------I------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- PERMIT No-_/4_7------------ ISSUED-----11-_2---7-- 5-1------.-(Date) FINAL INSPECTION BY:------A //#— ---------- Date----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT r 130 South American Street E5-9-2M 9-50 W=1639 Stockton, California