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3L� <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constru t and install the work-herein described. <br /> This application is made in compliance with County Ordinance No. 549. d,rf <br /> JOB ADDRESS AND LOCATION_ ----- . --/----------------------------------- 6 � <br /> � . � <br /> n ��--�- <br /> ✓Owner's Name------------------ ---------- -- ------- ------------------------------------------------------- - - ----- Phone � <br /> -------------- <br /> Address------------------------------------- <br /> -------------Address------------------------------------- "- avv, <br /> JG�Z <br /> Contractor's Name------------------------------ ------------- - <br /> ---------- ----------------------------- ---------------------------------------- Phone----�'`�� Q ------ <br /> Installation will serve: Residence WApartment House ❑ Commercial ❑ Trailer Court ❑ Motel F] Other ❑ <br /> Number of living units: ❑/ Number of bedrooms ❑ Number of baths ❑ Lot size_______________ --------------- _ <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 ❑ Hardpan [j <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic ank: Distance from nearest we€l---3_S_-----Distance from foundation----- ---------- <br /> depth-----_- -_--._-------- Material........ <br /> No. of compartments---_________2--________CaPacitY X0.9-0� Ze--- r r <br /> ---- -'� <br /> ------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-----------.____-------__-___________-- <br /> ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------- <br /> Privy: Distance from nearest well----------------_--------------------------------Distance from nearest building------------------------------------------ <br /> F1 Distance to nearest lot line------------------------------------------------ <br /> Seepage <br /> _______________ ____________________________Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line------_------- -� <br /> El Number of pits-------------- ------Lining material-----------------------Size: Diameter------------------------Depth-------------------- � }' <br /> Disposa Field: Distance from nearest well ------Distance from foundation--------------------Distance to nearest lot lin e-------- <br /> Number of lines-----------____ ---------------Length of each line___-_7-p-°______________.Width of french____a _ ----------- <br /> Type of filter material------ ----------Depth of filter materiaL_____�pu__-_-- <br /> Remodeling and/or repairing (describe)----------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------- I <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)-------------------------------------------------------------------- ----------------------------------------- -------------------------)Owner and/or Contractor) <br /> By:--------------------------------- -----(Title)--------------------------------- -- <br /> ---------•------------- - ---------------------------- - - --------------- - --- --------------------- <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---------------------------- -- DATE____3__ � l_________--- <br /> -------------------------------------------------------------------- <br /> --------------- <br /> REVIEWEDBY------------------------------------------- ----`-1--- ------------- ----------------------------------------- DATE------------- <br /> BUILDING PERMIT ISSUED--------------------------------------------------------------*--------------- <br /> ----------------------------------- ------------------------------ ------------- DATE----------------------------------- <br /> Alterationsand/or recommendations:----------------------------------------------- ----------------------------------------------------------------------------------------------=------------- <br /> ---------------------------------------------------- ----------------------------------------------------------------------------------------------------- --------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> PERMIT No.--3-�-�------------ ISSUED------ 3--4----Z5-/---- --------(Date) FINAL INSPECTION BY:--- / ------------------------------------------ <br /> DafieyL_-r ---------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />