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APPLICATION FOR SANITATION PERMIT i to " ' 7 Com lete in Du Z1 { Duplicate) p p 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. ��, �� :- ------------------------- .IOB ADDRESS AND CATI N------------ ------ --------- ------------------ --- ------- ==--- - � --------- --------- ---------- Owners Name....... _ ---------- Phone _!_ _. ----------------------------------------------------------------------- ------------------------------------- Address Contractors Name-------- Phone --------------------------------------------------------------------- Mofe Installation will serve: Residence �partment House ❑ Commercial ❑ Trai4er Court ❑ --ac! ❑ Other ❑ Number of living units: Eb Number of bedrooms �L Number of baths [ Lot size______ ^- -------•---------------•---- Water Supply: Public system ❑ Community system ❑ -Private Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ElClay Loam ❑ Clay ❑ Adobe❑ Hardpan TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 1i feet:] 4 Septic/Tank: Distance from nearest 3we`l__- ------Distance from foundafon-____. ____ -------.Ma�terial------ ------""--—=`fir-------------- r Lh' No. of compartment ---- gSize ------.Liquid depth--- ------------- s _________________ ac � :+ Cesspool: Distance fromhnearest well-----------------Distance from foundation--------------------Lining materia_____________________________________. ❑ Size: Diameter--------------------------------------Depth:.- ----------------- ----------------------------- Privy: Distance from nearest well------------------------------------_____________Distance from nearest building------------------------------------------- El _____-_ __________________-____________- ❑ Distance to nearest lot line------------------------------------------------ t Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_____-________-__ ❑ Number of pits---------------c.i�4Lining material-----------------------Size: Diameter-----•r----------------Depth--------------------------------� y y ' :. Disposal ield: Distance from nearest well __=� _--__.Distance from-foundation_��4______i Distance-to.nearest lot line--- CPO Number of lines_________I------------_ ________Length of each line---4-_-________r_+---Width of trench__{r----- ----` ----- Type of filter material._eva--- Depth of filter material------1_le__---____ k ---------------------------------------------------------------------- i - Remodeling and/or repairing (describe):-------------------- -------------------•- ------- -- - ----------------------------------------------------------------------------------------------------- ------------- herebycertif t I have prepared thi application and that the work will be done in accordance with San Joaquin County ordinances, Stat a d rules and re ul ions of t OSan�Joaquin Local Health District. (Signed)--- -------------------------------------------------------------(Owner and/or Contractor) Ti#le (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 APPLICATION ACCEPTED BY---------- ----- ------------------------------ DATE - --------------- )ATE-- -------------- REVIEWED BY -. DATE BUILDINGPERMIT ISSUED------ ------- ------- --- ----- ------------ -------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations------------------- ---------- -------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- l -------- -- --- ` CTION BY: PERMIT N&_-�--7----- ISSUED---------- __U -------------- FINAL INSPE Date-------------------- -�9/� -------------------------------- SAN --__SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California E5-9--2M 9-50 W-1639