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APPLICATION FOR SANITATION PERMIT 3 fl v (Complete in Duplicate) r ✓ 7`r� g7— Application 7-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. �- 1�A '/ s --------- •- JOB ADDRESS AN L ATIO /1►' ' t�� ?-- " " / t. Owner's Name �------------------ ------ ------ --- ---- Phone T Address �- ----------- ---------- ----------------- ------------------------------------------------------------------------------- Contractor's Name----------------- •---- - ------ ------- -------------------------- Phone------------------------------- Installation will serve: ResidA__ce1VV Apartment ouse ❑ Comm tial ❑ Tr er Court ❑ Motel ❑ Other ❑ Number of living units: ,r Number of bedrooms umber of baths Lot size_____/__4_A__73-___ Water Supply: Public system ❑ Community system ❑ PrivateX Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe 'Ha rdpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: q 1, (No septic tank or cesspool permitted if p//ublicnns�wer is available within 200 feet.) 01 Se ti Tank: Distance from nearest well-10-0--_Distance fro foundation-____ __ _.___.Material________ _________ _______________-_____. p ►j . No. of compartments------------��----Capacity__---- p Size_-- 3� _- .---Liquid depth-------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- ElSize: Diameter--------------------------------------Depth..-----•-------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_______-__----________________---_______-{ I+ ❑ Distance to nearest lot line________________________________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation__________________Distance to nearest lot line__ ____----_ l ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----_-----------------Depth------------------------ - R Disposal Field: Distance from nearest eII_In�____.Distance from foundation,__- a+.:.-.__Distance-to nearest lot line e�_;yy_�_ ------- Length _-___ Z Number of lines_____._________ J - �Length of each line_---____�p__9.--,-,,,-.Widfh of trench______ Ss�____________Type of filter material___._�"_Ckepth of filter material________ _ ___--_ Remodeling and/or repairing describe):_ - '--- R---- �- ~~�A ----------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 nod regulations of the San Joaquin Local Health District. (Signed) - ..... = --------------------------------------------------------------------------------------(Owner and/or Contractor) ----------•---•----------------------------------- ------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot p s, showing size of lot, location of system in relaflon to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT V5E ONLY / APPLICATION ACCEPTED BY------------------------------- ------------------------------- DATE- --------------- / ----------------------- -- REVIEWEDBY-------------------------------------------------------------------- DATE--------AD BUILDING PERMIT ISSUED ------------------------------------------ - DA: Alterationsand/or recommendations----------------•----------------- --------------•---------------------------------------------------------•--------------------------------------------------- ------ ---- - - - ------ - - �1----- ------------------------------------------------------------- ------------------------------------------------- ------ --------- ------------------------ ---------- ---- -- ---------------- - --- ----------------------------------- r PERMIT No. -�_Y_ ISSUEQ_____________ ____3_ __ � (Date) FINAL INSPECTION BY:________-_---_-----_--_____-- i__---------------- Date------------------- / -tS----- Z�--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639