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APPLICATION FOR SANITATION PERMIT W r <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 No. 549, <br /> JOB ADDRESS AND LOCATION------------------------------------ <br /> = Y <br /> ------------------------------------------- <br /> 40_1_61 <br /> Owner's Name----------------------------------------------------------�_=-�----.-<---.t ------------------------------ Phone-- - <br /> --------- <br /> ------------------- <br /> Address ------------------------------------------- ----------- f <br /> �_ <br /> x - <br /> Contractor's Name_ = .. i r ..� Phone-------------------•----- - <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ❑ Number of bedrooms E] Number <br /> Number of baths Q Lot -size_________r_�_____:' -------------------------------------------- <br /> Water Supply: Public system [f' Community system E] Private E] nW <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay p Adobe 0 Hardpan ❑ O <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-_-___,:9---------Material_"'___:____:______--_-______________-__________- <br /> No. of compartments---------1---------------CaacitY hSae ,1`)= a'--- ---- - Liquid depth---_'_�__-- ---- <br /> ------__---. <br /> Cesspool: Distance from nearest well-----------------Distance from foundation____________Y_____-Lining material.------------------------------------ <br /> ElSize: Diameter-----•--------------------------------Depth---------------------------------------------------- <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> El Distance to nearest lot line________________________________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------.Distance to nearest lot line----------------- <br /> Number <br /> _-- ____-_-__ <br /> ❑ Number of pits------------- ------Lining material-----------------------Size: Diameter------------------------Dept h----------.---------------------- <br /> Disposal Field: Distance from nearest well------------------Distance from foundation_____________----__Distance to nearest lot line_._r-___________. <br /> Number of lines__.....--__________________ Length of each line_____4_6?______�__-----Width of <br /> Type of filter materiaL�r!� -----Depth of filter material----1__� ----- <br /> Remodeling and/or repairing (describe): _= -------------------------------•----------•------------------- <br /> ----------------------------------•----------------------------------------------------------------------------- <br /> --------------- <br /> -----------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------_.------------------------------- <br /> 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)..-----------' � -sem' '^ - <br /> - ----------- (Owner and/or <br /> -----r � <br /> -- ----- F .-_' ------------------------------- ------------------------(Title)- =r�,�.,�� FContractor) <br /> gy:-_ <br /> (Plot plans, showing size af�lot, location of system in relation to wells, buildings, etc., must be filed with this applic�i nn). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY j� ------------------- ---------------------------------------- DATE--------- � = <br /> REVIEWED BY------------------- - �" ---- .{ <br /> -------- -- <br /> - ------------- -------------------------------------- ------------------------------------ - ------ DATE------------- ------•----- ----------------------------- <br /> BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE. <br /> Alterationsand/or recommendations:-----•-------------------------------------------------------------------------------------•---------------------------------------------------•-----------•--- <br /> -------------------••----------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------•------------------------- <br /> ---------------------------------------------------•-.-----------------------------------------------------------•------------------------•-•------------------------------------------------------------------••------------- <br /> ------------------------------------------------------------------------------------- --------------------------------------------------------------------------•-•------------------------------------------------------- <br /> ----------------------------------------------------------------- ------ -------------------------------------------------------------------­­-------------••-------------------------------------------------------- <br /> PERMIT No._6_., ---r----- ISSUED-,--- 3-- 3 ''s�(Date} FINAL INSPECTION BY_____________ <br /> Date_ <br /> ------------------------ - ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />