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i <br /> ' t <br /> APPLICATION FOR SANITATION PERMIT ` <br /> (Complete in Duplicate) i� <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 compliancewith County Ordinance No. 549. 7� e- <br /> JOB ADDRESS AND <br /> /LOCATION------5..�-�trll_� _-- � .?-�--- 1 /�1� �-�-=---------------------------- <br /> Owner's Name----------- -------JAcrt- -•s5--------- ---------------------------------- <br /> -- Phone 1 I- u <br /> moi/ � <br /> Address---------------- _---- � k <br /> -------- ' ----- <br /> Contractor's Name----------------------------- ------------- Phone----------------------------------- <br /> Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ MoteE]ell F1 Other <br /> Number of living units: [] Number of bedrooms 5, Number of baths Q Lot size---------6-- - x �>�'--_d----- <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 W Adobe ❑ Hardpanj,`'-- <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 /> F1Size: Diameter--------------------------------------Depth------------------------=--------------------------- <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> 0 Distance to nearest lot line________________________________________________ <br /> 'Seepage Pit: Distance to nearest well___--114_Distance from foundation----2v-------.Distance tq nearest lot line__._,:66-___ <br /> 5+� .0"I "Number of pits_____/--------------Lining material___J9&d"Wa_64Size: Depth------- _________ f <br /> Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line____.____________ <br /> '�' ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- a <br /> Type of filter material----.-----------.-_._____Depth of filter material_______________________ <br /> Remodeling and/or repairing (describe)------------------------------------------------------------------------------------------------•------------------------------------------------------ <br /> -----------------------------•----------------------------------------•-------------•-------------------------•--------------------------------------..-..-------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------- <br /> hereby certify +hat I have prepared this application and +hat the work will be done in accordance with San Joaquin County <br /> ordinances, a d1laws, nd rules and regulations of the San Joaquin Local Health District. <br /> Signed) --- --- ------------------------------------------------------------------------------------------------(Owner and/or Contractor) <br /> By:------------------------ ----------------------------------------------------------------------------------(Title)--------------------------------------------------- ------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br />„- <br /> I APPLICATION ACCEPTED BY-------- -- `--- LDATE b <br /> -------- --- --- -------k -------- <br /> REVIEWED BY ---------- - DATE <br /> ----------- --------------- ------------------------- <br /> BUILDING PERMIT ISSUED----------- ------ DATE------ �,�-•� '"I <br /> Alterations and/or recommendations:--------------------------------------------------------------------------------....... ----•------ ,.--•---------------------- ---------------•----------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ----------------------- ------•-------------------------------._.----•--------------------------------------•---•---------------------------• --•----------------------•-----•------- ----- <br /> (­'�PERMIT No. --- ISSUED--- 'G / � r <br /> - r/j2 (Date FINAL INSPECTION BY:---- <br /> Date_ ------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />