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{ 1 i PPLICATION 'FORt SANITATIO (Complete in Duplicate) Application is hereby made to the San,Joaguin 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. p ` y,� = _ its-ice'------- JOB ADDRESS AND LOCATION---------- -------- �� ' - . . Phone--------------- -------------- Owner's Name------------ -----� - rq "Addr ---------'-----------------•------------------------------------e ° -- Phone _ -------- Contractor's Name_______ Installation will serve: Residence 16 Apartment House ❑ Commercial E] Trailer Court ElMotel ❑Other ❑ Number of living units: Z Number of bedrooms [:I- Number of baths 4 Lot size____�_5?__k-/--C?__tx------------------------------ Water Supply: Public system 19 Community system El Private E] Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Gay Loam ❑ Clay ❑ Adobe, 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 ______________Distance from foundation------------------=.Mafierial------------- ----------------------------------- ` --------Ca Capacity -----------Size--------------- --•--a---- Liquid depth--------------------------- ❑ No. of compartments . ' Distance from nearest well_________________Distance from foundation_.____-___________Lining.material_'__________-_.--------------------- Cesspool: w ❑ Size: Diameter------------------------------------Depth---------------------------------------------------- i ' i ___._.Distance from nearest building-____1______________________________`-- �, '' :Privy: Distance from nearest well---------_-------------------------- � . ❑ Distance to nearest lot line----------------------------------------------- r Seepage Pit: Distance to nearest well_------''_'----Distance from foundation_____- ,_------ to nearest lot line______________ � 04 p J ing material--- from Diameter_.__a!__4--_____--__. _Depth-----�-- -•�------------- Number of its---- ------------- -Lin t !I Disposal Field: Distance from nearest well--------- _____.Distance from foundation_-__-t- .--___Distance to nearest lot line=.Ael______- Number of lines-----_-----1---✓----------------Length of each line-----�c_�---------------Width of trench-------- '`'l ----------------- T --------------- Type of filter material C, __Depth of filter material___-_ - _____ . Op Remodeling and/or repairing (describe):-- f ----------------------------------------------- iI ---------------------------------- ------------------------- ------------------------ -------------------------- - a__________________________________________ __________ _______________________________________________________________________________________a_________.__+____________________a__________-______-______-_____ I hereby certify that I have prepared this application 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. i a I X21 '__. 7____ r and/or (Signed)- Contractor) ---------------------------- (Owne By:__----------------------------------------_---------------------------------------------------------------------- + -----(Title)-----Lr'-,• ? -- (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 r APPLICATION ACCEPTED BY------------ ----------- --- ----- - = : i -------------- -- --- DATE _. REVIEWED BY_ ------- v------ ----=----- DATE: y --------------------------------------------------------------- - - DATE------------- ---------------------------------------------- BUILDING PERMIT ISSUED + -- i ------------------------ -- ------------------------------------------------- Alterations and/or recommendations:_______________________________________________ -------------------------------------------------------- - ------------------------------------------------------=------:----------------- . ------------------------------------------ ---------------------------------------------------------------------- r _ ---------- - ---------------- �f - -- Date FINAL INSPECTION BY-- ----------------------------------------------- PERMIT No.----------'-------------- ISSUED-=---- ----T--�-------•------- - (Date) iDate-------- ----- � f �'----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT .z. 130 South American Street r ockton, California E5-9-2M 9-50 W=1639 .f