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-= INk - / 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 No. 549. JOB ADDRESS AND LOCATION-----C> -------------------------------------------------- ----------------------------- -------------------------------------------------------- Owner's -------------------------_-------------------------------------------------------- Owner's Name------ ter t./'_- ! Phone-------- ---------------------------- -- ------------------------------------------------------------------------------------------ - Address-----��------- -------------------t------------------------------------- ---------•----------------- - Namef N ' ----------------------------------------------- Phone----------------------------------- Contractor's --- -----Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: V1 Number of bedrooms RL Number of baths [A Lot size----- -.--_------------------ Water Supply: Public system ❑ Community system ❑ Private [� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ ` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S ank: Distance from nearest well------------------Distance from foundation-------------------.Material-------------------------------------.----------- No. of compartments--------------------------Capacity-----------------------Size----•---------------------------Liquid depth------------ -------- ool: Distance from nearest well_---------------Distance from foundation--------------------Lining material------------------------------------- Size: -__--- __---.-----_.---- ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- r 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--------------------------------- -.Dispo I Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line----------------- Number of lines-----------------------------------Length of each-line---------------------'---------- Width of trench-----------------------------------_ Type of filter material-------------------------Depth of filter material----------- -_---_--- -Remodeling and/or repairing (describe):-------- *---" t 1 -S- , r---�•--"- ------------------------------------------------------------------------------ '" --�' I hereby certify that I have prepared this application'andthat the work will be done in accordance with San Joaquin County ordinances, State laws, and .rules and regulations of the San.Joa,quin LocallHealth District. (Signed)-_x-------- __. -_ ------------------------------------(Owner and/or Contractor) By:----- " -------------- ��- ---------------------------------------------(Title)-----------------------•---------------------------------------- (Plot plans, showing size of lot, location of systerrt�in..relation to wells, buildings, etc., must be fled with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------------ --------------------------- ------- DATE -- ----------- REVIEWED BY--------------------------------------------------------------------------------------------------------------------------- DATE - - BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE--------------------------------- ------------------ Alterations and/or recommendations------------------------------ ---------------------------------------------------•--------------•--•--------------------------------------------------------- --------------------------------------------------------------------------------------•--------------•--------------------------------------------------------------.•.-------------------------•------------------------._.- ----------------------------------------------- ----------------- � ------------------------------------------------------------- -------------- -•----------------- --------------------------------------------------- ---------- ---- - -- - - - --------------- PERMIT No.-- -"i-�------------- ISSUED-_..Q\-1`6! 5c----------(Date) FINAL INSPECTION BY:------------ ' --------- ---------------------- Date----------------------------------- --------: .:. ------.------ SAN JOAQUIN LOCAL HEALTH DISTRICT S ric, 130 South American Street 11 E5-9-2M 9-50 W-1639 Stockton, California