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D APPLICATION FOR SANITATION PERMIT �b ` (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. I This application is made in compliance with County Ordinance No. 549. Ir JOB ADDRESS AND LOCATION____________ --------------------------- /�� Phone-- ------------------ ------------- Owner's Name--------------�es�� `�`_ V,----------------------------------------- ' r , - ------------------------------ } ----------------- - ------- -- ii ----------- Phone------------------------------- -Contractor's Name__. 14 frL ------------------------------------ ----=.------------- ------- Installation will serve: Residence 1h Apartment Hduse ❑ Commercial '❑ Trailer Court ❑ Motel ❑Other ❑ Number of living units. ❑ Number of bedrooms Number of baths ❑ Lot size-------------------------------------------------------------- Water Supply: Public system ❑ Community system ❑ Private LK Loam Cla ,Loam Clay ❑ AdobeV_H-ardpan ❑Character of soil +o a dep+h of 3 feet: Sand ❑ Gravel ❑ Sandy ❑. y ❑ , !' TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if.public sewer is available within 200 feet. fro dation =-�� ----------- - terial----- Septic �!�. _ . Tank: No. of compartments e fro t_well----- --,---Capacity ---- f :_Size___ef.XA X --------Liquid depth- ------- ----------------. N•. • Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining�materia_s_ -_- ❑ Size: Diameter--------------------------------------Depth-----------------------------------=------- ----- Privy: Distance from nearest well------------------------------------------------- ante from nearest building________.__._._----______ Distance. � �,,. � .•. .� , See a e Pit: Distance to nearest well---------------------- from foundation____ ❑ Distance to nearest lot line------------------------------------.----------- Seepage _------__ "'I------------Distance to nearest lot line-______________ , p g •�. ❑ Number of pits-------------•--------Lining material-----------------------Size: Diameter = = -------:Depth---------- ----------------- Dispos 4 Field: Distance from nearest well __ 4_'_.Distance from foundation___-___ _ Distance to nearest lot lin ____ _ ______ n^ r Number of lines-------___-- Length of each line_-----j_0 ---------.Width of trench---------- --------------------- Type of filter material��_�__----Depth of filter material______'Wr 914.____ Remodeling and/or repairing {describe)---------------------_- --_--------------------- --------------------------------- 1 ------ - -------------------------- --------------------------- �- ='"" Y I hereby certify that I have prepared this.application and that the work will be done in accordance"with San Joaquin County ordinance State laws, and rules--angulations of the San Joaquin Local Health District. Gam.,•✓ -----------------------------------------------------------------------_----(Owner and/or Contractor) {Signed}--- ----------- - ---- �- --• ~------- - - .__ -----------------(Title)------- {Plot plans, showing size o of, location of system in relation to,wells, buildings, etc., must be filed wifh +his application]. s FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------------------- DATE------- lQ I� -------------- REVIEWED BY-------------------------------------- -------- - DATE BUILDING PERMIT ISSUED--------------------------------- DATE - -.` Alterations and/or recommendations--------------------------------------- --------------------------------------------------- ------------------- ----------------------- --------- ------------------------------------------------------------------------------------------------------------ - - PERMIT No.--(,. ISSUED__ 1 -(Date) FINAL INSPECTION BY: -------,-------------------------------------- { Date--------------z cZ � �/7------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 4-50 W-1639 _