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k 4 APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Application is hereby made to fhe 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___ -_-- __d_;,� �� -------------------------------- --------------------------------------- Owner's Name__ ----------- -------------- Phone------------------------------------ -------------------------------------------------------------------------- Address----� _- Contractor's Name_ --------- ------------------------------------------------------------------------------------------------------------------- Phone_----_--------------- -------------- Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of living units: T Number of bedrooms [2- Number of baths Q3 Lot size_____-___6�0 ___ Water SuPP!Y� Publics stem Community system ❑ Private I� Character of soil to a depth of 3 feet: Sand [) Gravel ❑ Sandy Loam ❑ Clay Loam ❑ . Clay ❑ Adobe [A/Hardpan ❑ 4 TYPE OF. INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_¢ Distance from foundation--,, _(1 :Material_______ _No. of compartments____ _________________Capacity_.- -_ -Size__�� _ _ :_i __ -•Liquid depth-------4 --------- ------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- Size: -______-__________---_________Size: Diameter--------------------------------------Depth--------------------------------- ------------------ Privy: Distance from nearest well------------------------------------------------- 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--------------------_---- _� Disposal field: Distance from nearest well ._ Dis+ante from foundatio Distance to nearest lot line__ __ �+[ .-: 'um � _ �e ' -'- a-..�w.� Number ofTinesLengt of each G __ W0d 1h of trench______' �'' - `� --------------- Type of filter material----- -- /f. 'Depth of filter material------ -=_----____- x Remodeling and/or repairing (describe)_______________________________ ' ----------•-----------------------------------------------------------•--------------------------------•--------------------•---------------------------------------------------------------------------•------------------ I -------------------------------------------------------------------------------------•------------------------••-- 1 _-----•--------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------ 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. ---_- (Owner and/or Contractor) # BY:------------------------•------------------------------------------------ - ----------- --- Title ------ - ------•--- P of plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application), k FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- ----=----- ------------------ DATE ' { --•--------- REVIEWED BY---------------------------------------- -------------------------------------------- ----- DATE i ------------------------------- - UILDING PERMIT ISSUED-------------------------------______---------- , ----------�--------- ------------------- --------- DATE__-------------- ----------- --- - - ------------------------ terations and/or recommendations------------------------------------------- -------------- -------------------------------- - --------•------------------------------------------------ 40 ------------------------ -----------------•----•----------------•--------------=---•-----------•----------------------------------------------------------------------------------------•-------------------------------------- ------ 3 -----------------------•- ----------- --------------------- ------------------------- -------------------------''--------------------------------------------------------------------------------------- ---------------------------------------------------------------- { PERMIT No._70V-r`_- ISSUED----- ___3[rJ_ --__----(Date) FINAL INSPECTION BY______________ - f ------------------------------- Date ----------------- Date------•----------- i' __� 4""I F � --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT a 130 South American Street Stockton, California / ES-9-2M 9-50 W 1639