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' <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> M <br /> r 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 /> � , . <br /> JOB ADDRESS AND LOCATION----------- -��----"---�-------------e. ----�=--14---6--------------- ----`r--- i�`/ -------------------------- __A_S____j------- <br /> Owner's Name-------- 1"'_ - `{------------ --- '---'--------- ---------�------------------------------------------------ <br /> r <br /> Address--------------------------- a�'-___` =------------------------------------------------------------------------------ ---------------r------------------------------------------------------------ <br /> Contractor's Name________________________; 1--p—Al � <br /> --- -- ry---13 1 � --------------------------------------------- Phone--- <br /> Installation will serve: Residence'[] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ❑ Number of bedrooms ❑ <br /> � ❑.� Number of baths t Lot size-----�,�k- <br /> Water Supply: Public system ❑ Community system ❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 12E Hardpan ❑ <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---------------------Material----_____----------__-_--_---------__------__--- <br /> ❑ No. of compartments--------------------------Capacity----------------------Size------------------------- ----Liquid depth--------------------------***-A <br /> Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- <br /> EiSize: Diameter----------------------------- ------Depth---------------------------------------------------- <br /> Privy: Distance from nearest well-------------------------------------------------- from nearest building-----------------_-------------- _---.-_. <br /> ❑ Distance to nearest lot line________________________________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-------___-____- <br /> Number of pits----------------------Lining material-----------------------Size: Diameter--_---------------------Depth--------------------------------- <br /> Disposal Field: Distance from nearest well-------1-- ---.Distance from foundation=_____-- -:--Distance to nearest lot line =_----- <br /> ' Number of lines----_______I----- Length of each line__--/---0-_�___----- Width of trenc --------------------- <br /> A' -. r. <br /> Type of filter material----�__!,_1.6(-k+_Depthhoof�filter material---------9------------- <br /> Remodeling and/or repairing (describe)---------------- 4�<YYA. "y--------------------------------------------------------------------------------------------------------• i <br /> ---------------------•--------------------------------------------------------------- •----------------------•--------------------------------------------------------------------------------------------------------------- <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------­- •---------... ---------- <br /> --------- ------- <br /> --------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 4 <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 /> (5i ned � ���'", !� ------------- Owner and/or Contractor <br /> 9 } -- ----- ------i-------------- ---------------------------------------- ( /a ) i <br /> ----(Title)----------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------------------------- I --------------- DATE------------3 ---- -- ----------------" <br /> REVIEWED BY �— <br /> ---------------------------------------------- DATE --- -- <br /> - --------------------------- <br /> 5 <br /> BUILDINGPERMIT ISSUED----------------------------------------------------- ------------------------------------------------ DATE------------------------------------- <br /> Altera ons`avndnd/oyfie-,nco�mmegdatons: <br /> -- <br /> ------- <br /> ------------------------------------------ ----------------------------------------------------------------------------- , <br /> .- - -9 -------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ <br /> 57- <br /> PERMIT No------------------------ ISSUED------3-------------------------------(Date) FINAL INSPECTION BY:---- - ---��--- --------- -------------------- <br /> Date--------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> E5-9-2M 9-50 W-1639 <br />