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APPLICATION FOR SANITATION PERMIT 6 Z v <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance N 549. <br /> JOB ADDRESSAO LO TION -------- ------ ------------------------------------------------ <br /> -------------------- Phone------------------------------------ 1 <br /> Owner's Name_ _ _...---�p <br /> Address------/Q----le .0---------69 -------- � '------------------------------------------- ) <br /> /---- <br /> Contractor's Name--- „ < H' /_.r �h-_ �3, mss. Phone-- --- �-- -------- <br /> Installation will serve: Residenc Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: Number of bedrooms Number of baths Lot size_____ -------- ------________ <br /> Water Supply: Public system Community system ❑ Private ❑ '' <br /> Character of soil to a depth of 3 feet: Sand•❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material__________________-______________---------__---- <br /> ❑ No. of compartments--------------------------Capacity-----------------------Size------------------------------- Liquid depth------------- --- --- --- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_______________________________.____. <br /> [] Size: Diameter--------------------------------------Depth--------------------------------------------------- <br /> Privy: Distance from nearest well--------------------------------------------------Distance from nearest building-------.________________________-____-. <br /> ❑ Distance to nearest lot line_ _____________________________________________ <br /> /� p J <br /> See a e Pit: Distance to nearest well---d%-,--------Distance from fo dation____�,r_V___-r Distance to nearest lot line__�Q___'` <br /> Number of pits______________ ___ i F ! <br /> _ __Lining materfal__0% _ _Size: Diameter______ ___ _ _ ____ p <br /> _Disposal Field: Distance from nearest well_w----____.Distance from foundation____/rte`__-----Distance to nearest lot line__ _0------- <br /> Number <br /> '___Number of lines___________ __ Length of each line______ r _ Width of french-------a ------------- <br /> Type of filter material-_"IC_ / ,__Depth of filter material_______ ----- <br /> -Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------ ------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------•:-------------------------------------------------------------------------------------------------------------------------------------- ------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and.regulations of the San Joaquin Local Health District. <br /> (Signed)--___0__ '--=-_ 1,�_a-_ _•4_ Scr.--- -------------- - -------------------------------------------- ---- or Contractor) <br /> By:----Aowing!*si�'�'of <br /> - ------------------ (Ti+le� f --------.----------- <br /> (Plot plans, s lot, location of system in relation to wells, buildings, etc., must be filed with this' application). <br /> `l FOR DEPARTMENT USE ONLY ` <br /> APPLICATION ACCEPTED BY-------------------------------------- ----- DATE S'1-------------- <br /> ----------------------------------- <br /> REVIEWED BY---------------------------------------------------------------------------------- <br /> DATE <br /> BUILDINGPERMIT ISSUED------------------------------------------------------------- --------------------------------------- DATE-------------------------------------------------------------- <br /> Alterationsand/or recommendations-----------------------------------------------------------------------------------------------•------------------- ------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> --------------------------------------------•------------------------------------------------------------ <br /> PERMIT Noj-,2_(1------- ISSUED--------- --3_-3-- _-S7 --(Date) FINAL INSPECTION BY:---------' --[l.__ --------------- <br /> Date--------------------5__2m---- --------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />