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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) c �- D Application is hereby made to the San Joaquin Local Health Dist ricf for a permit to construct and install the work erein described. This application is made in compliance with County Ordi e No. 549. � JOB ADDRESS AND Owner's Name------ --- - -- - -------------------------- - - ------ Phone------------'----------------------- --1I -------------------------------I---------------- ontractor's Name •---- -------------------------------- -------- - Phone---------------------------------. -- Installation will serve: Residence [ artment House ❑ Commercial ❑ Trailer Court i ❑ Motel ❑ I,Other ❑ Number of living units: Number of bedroomsg+lMumber of batot size-_ Ate� r Water Supply: Public system ❑ Community system E] Private ' Character of soil to a depth of 3 feet: Sand El Gravel ❑ Sandy Loam ❑ Clay Loam El Clay El Adobe Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Septi T Distance from nearest well-------------=---Distance from foundation--------------------Material No. of compartments--------------------------Capacity-----------------------Size---------------------------- - --------------------- -- Liquid depth Disfance from nearest well-----------------Distance from foundation--------------------Lining material---___--_---___------_"--___-_ ❑ Size: Diameter-------�------�----------------------Depth------------- ---------- - ----------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building - Distance to nearest lot line ----------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation """___.Distance to nearest lot line"___""-__"____"_ ❑ Number of pits----------------------Lining material--------------,--------Size: Diameter-----------------_"_--.Depth------------____-- p -------------- _ _ a. Field:y _Distance from.Tnearest.4well__j�-.--.Distance-from.foundation-_ ""-""" -- ________Distance to nearest lot_ ine___ __"" -� Number of fines_____,""""--_�-----------__"_ Length of each line____""""��__`! V1/idth of trench____ _�_�_____ ____________ Type of filter materiaL_ i �"Qf.. Depth of filter material-___ r-_ __ - { ,8 i Remodeli and/or repairing (describe A -- r IPA--------------- - 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. (Signed)---------------- - X774- (Owner and/or Contractor) - .. SY:--------------------------------------------------------------- ---------------------------------------------------------------Title _______ (Plot plans, showing size of lot, location of system in relation to wells, buildings, efc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ---------------- DATE- REVIEWED BY -" -------- DATE---- BUILDING PERMIT ISSUED -- --- -------------------------- -- DATE__ -- Alterations and/or recommendations___ - ----------------- ti ----------------- ----- - ------------- --- -- - ---------------------•-----------------------•-------------- ------ ---------- ------------- -- --------------------------- - --- --------------- ----------------------------------------------------------------------------------•------------------------------- ------ ------ - - -------------------------- PERMIT No------------------------- ISSUED------------------------------------------(Date) FINAL INSPECTION BY------- __-- "-- ----------- ------------------ Date .5 - ----~'------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W-1639 Stockton, California 1