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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 N 549. JOB ADDRESS AND LOCATION--02;Z-19-9 - - -_-- ,FAQ _Owner's Name-----/71 ---- ----- - - ---------- Phone------------------------------------ - ----- ------------------------- - ------ ------ - ------------ -------------------------------------------------- Addrens o - Contractor's Name---- Installation ame---Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ` Number of living units: � Number of bedrooms �J Number of baths ItLot size__��7_�: ` �,,� _ � -__________________________ x Water Supply: Public system Community system ❑ Private [) Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX 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--------------------Material __�______________________________ , ❑ No. of compartments--------------------------Capacity---------------------Size-------------------------------Liquid depth-------------------------- Cesspool: Distance from nearest well-----------------Distante from foundstion--------------------Lining material---------------------------- _ ❑ Size: Diameter------ -------------------------------Depth---------------------------------------------------- -~ -4 Privy: Distance from nearest well----_---------------------------------------,___Distance` from -nearest building____----.________-_ ---------------------- El Distance to nearest lot line-----------------------------------------------• _. Seepage Pit: Distance to nearest well___ _ ----------- stance oma€o dation____�,� �___ Distance to nearest lot line___-��_ _ Number of pits___-__/_____-______LS inin maaterial-__s_�/,�_Size: Diameter-,-___a j'ee rte.+ .Depth k ------------------- Disposal Field: Distance from nearest well---_T _ _.Distaance from foundation�141------Distance to hest lot li e_--1 Number of lines______-_-_ .__ _ _ Length of each line------ ; Type of filter material___ .t___IJ Depth of filter material------J�__--__ i Remodeling and/or repairing (describe):--------------------------------------- - .____-___- --------------- ----- -------------------------------------------------------------- { ----------------------------------------------------------------------------------------------- -------------------------------------- ------------------------------------------------ -------------------------------------- ------------------------------------------------ :`------------- ---------- ------------..--------------------------------- 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' regula+ions of the San Joaquin Local Health District. (Signed) QC/ " J,fl sem^- _ ---- ----------------- ------_------ ----- d/or Contractor)- -.. --------------------- Y'-- ---- ------------ ---------------- ------------------- - ------------(Title)-�a�i-•C�,__ _-rr�.--------- ---------------- - (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - _W--------------------------------------- DATE------� �` REVIEW ED BY. - -------------------------- -------------------------------------------------- DATE--------- -------- -------- BUILDING PERMIT ISSUED-------------------------------------------------------------- ----------------------------- -------- DATE ------------------------------------ Alterations and/or recommendations:----------------------------------------------------•----------------------------------------------- ---- - ----------------------- ---------------------------------------------------I----------------------I------------- ------------------------------------------------------------------------------------------------------•---------------- ----------------------------------- ---------------------------------------------------------------- _% ---------------- --------- --------------- PERMIT No. ISSUED___--_ _-_ -� �_-__-----(Date) FINAL INSPECTION BY:_____ t- - Date----------- � .�1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California1 ES-9-2M 9-5o W=1639 - e