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f APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Application is hereby made to the San Joaquin Local Heafth District for a.permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. I JOB ADDRESS AND LOCATION__________.___ ___ _ __ ----- ----- ------- --------------------------------------------------- Owner's Name------ lam- � �- --------------- Phone---=-------------------------------- -- ---- ---- - - --- -- Address--------------- _- - ---------------------------- 1 >�rf �� k �e °a - tf� ' �E Contractor's Name-----------------•------------------------------------------------------------------------------------ ------------------------------------- Phone-----------------------------------A Installation will serve: Residence( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ] Number of bedrooms �& Number of baths 4 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.) N ' Septic Tank: Distance from nearest well_ -•---Distance from foundation--�I.5--_------Material----- ------------- No. of compartments---------�------------Capacity--�j 7_____Size------:tD( g___-_----Liquid depth-----7---__ V Cesspool: Distance from nearest well-_='_�": Distance"from foundation--------------------Lining material------------------------------------- F1 ____---_---_ ------____----____---.- ❑ Size: Diameter--------------------------------------Depth=-------------------------------------------------- i Privy: Distance from nearest well--------------------------------------------------Distance from nearest building-----------------------------------------) ❑ Distance to nearest lot line------------------------------------------------ Seepage ______________________________________________Seepage Pit: -Distance to nearest well----------------------Distance from foundation---------------.----Distance to nearest lot line---------.__---_- ❑ Number of pits-------------- ------Lining material-----------------------Size. Diameter------------------------Depth---------_----------------------- Disposal Field: Distance from nearest well_40_______Distance from foundation__d�� ______Distance to nearest lot lirle�l ® Number of lines-----------_f Length of each line____ _ ------------Width of trench__ Type of filter materially 40,� __Depth of filter material_________________ Remodeling and/or repairing [describe _________________ ------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------I------------------------------------------------------------------------------- I hereby certify +hat I have prepared this application and that the work will be done in accordance with San Joaqu7in-6ounfy J ordinances, State laws, nd rul a d regulations of th an Joaquin Local Health District. (Signed)------ = ----------------------------------------------------------------)Owner and/or Contractor) By:--------------------------------------------------------------------------------------------------------------=------------------(TFtle)---------------------------------------------------------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- - - ------------- -- ---------------------------------------------- DATE----------?_ ------------------ - - ---- REVIEWED BY-------------------------------------------------------------- - ------------------- --------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations----------------------------------------------------------------------------------------••------------------------•--------------- --------------------------- I -------------------------=------------------------------------------------------------------------------------------------------------ -•------------•------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------- -------------------------------------------------------------------- -- ---------------------------------------------------------------- -•----•--------------------------- PERMIT No._ d-____-- ISSUED--------- -----------(Date) FINAL INSPECTION BY:------ -----------_I----------------- t Date_ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9=2M 9-50 W-1639 `�