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APPLICATION F T F OR SANITATION PERMIT (Complete in Du /� Duplicate) 1 ' P ) 1 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--------- �' Q Owner's Name----------------------wive---------- J- " --------------- ------------ Phone---------------- --- - -- ------------------------------------------ Phone ----------- ----- r� Q �� / , --------------------- -- Contractor's Name------------""-- . --- ------------- Q _ l-------•--------•---- -------------- Phone_ Installation will serve: Residence ❑ Apartment House ❑ Commercial 0 Trailer Court Number of living units: ® Numberf bedrooms of ❑ Number of bath ❑ Motel E] Other, G�,�,'�,� s Lot size--------------Q Water Supply: Public system Communitysystem - Y ❑ 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.) Septic Tank: Distance from nearest well-----------------Distance from foundation_____1' Material____________"_ ---------------------------------- El No. of compartments--------------------------Capacity-----------------------Size--------------------- ------------------ Cess ool: Distance from nearestwell_______ _ Liquid depth________________________ ___Distance from foundation Lining material GP :r` t a Size: Diameter---- IF, ---r,---------------Depth------------4 ---------------- - Privy: Distance from nearest well_______________________ '" ----------------------"--Distance from nearest building--------------- -"-- ' ❑ Distance to nearest lot line----------------- Seepage Pit: Distance to nearest well-----------------------Distance from foundation__-,_______.____ ❑ Number of pits_____________________lining mae�ial__,____ Distance to nearest lot line__--_______--__ ----------------Size: Diameter_----------------------Depth---- _Disposal Field: Distance from nearest well --------- Distance from foundation___________________Distance to nearest lot line______-_________- _ # ❑ Number of lines--------•-------------- ------- -_"L-eng}h of each line------------------------------of filter material ---Width of french_-________-_____-___-_______---___ __Depth of filter material_______________________ Remodeling and/or repairing (describe):____________ _ - _ _ _ _ _ _:__=___:_ .------------------ -------------------- ------------- ---- -, I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta laws and rules and egulations of the San Joaquin Local Health District, (Signed)--- ---------------- -- - --- -------------------------------(Owner and/or Contractor) -------------------------------------------------------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, efc., must be filed with this application). Tifle)--------------------------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY________________ DATE-------- .� VIEWED BY -- ------------- --------------------------- ------------------- DATE BUILDING PERMIT ISSUEQ.___________ s 1 DAT.E ------------- Alterations and/or recommendations: _ � d --------"---------------- -- - -' _______________________________ __________________ __________________-_______-______--______--_-___ _____ _______________________________________.------------------------------------------------------------------------------------------------------------- PERMIT No. �j -----/"-d'-- ISSUED----- a! �-- _ "(Date) FINAL INSPECTION BY: `�--V14___""_--"--_"- - , ----- -- ---- Date �{� ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W-1639 Stockton, California