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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) App kation ishereby 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 LOCATIO .- ' � a - --------------------------------------------------------------------- Owner's Name------- , ----------------• Phone----------------------------------- Address------------------ - �0 ------- --- ------------- --- -- Contractor's Name---------------------------------------------------------------------------- ------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence Apartment House E] Commercial [-] Trailer Court E:] Motel [:] Other E] ' Number of living units: 0 Number of bedrooms [Number of baths Ud Lot size----- _��Cis��. ______________________________ Wafer Supply: Public system ❑ Community system ❑ Private x Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.] Septic Tank- istance from nearest well_________________Distance from foundation--------------------Material______________--____----_-_---__________________ o. of compartments---•----------------------Capacity-----------------------Size--------------------------------Liquid depth--------------------------i Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material___________________________________7 On ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------- 1 Privy: Distance from nearest well-------------------------------------------------Distance 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------------------------Dept h--------------------------------! // t DIS osal F Distance from nearest well____-O_-d____Distance from foundation____ -------Distance to nearest lot`J.iie:__ _ _ f Number of lines_____________I------------------ Length of each line-------� _Q {----Width of trench--- - ----------------- Type _-__--_--_--___Type of filter material-s'r__� �Depth of filter material________------------ Remodeling u--_____Remodeling and/or repairing (describe):--- - ------ ---------- ----`-------•----------------------------- i - �� ----� = = == - ---------------------------------------------------------------------------------------------------- ---- --------------------------------------------------------------•-----------------------.-----��------------------------------------------------------------------------------------------------------------------------� hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaqu' Local Hea h District. - f r Si ned,)�"'t !�� __________________ _______(Owner and/or Contractor) U SY= ----- "' _ wR �" '' ------------------------------------------------------------(Title)---------------------------------------------------------------- (Pio+ plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTM NT USE ONLY APPLICATION ACCEPTED BY---------------------------- -r--- ----0-511 - --------------- DATE----- REVIEWEDBY------------------------------------------------------ ---------------------------------------------------------- DATE-- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------ Alterations and/or recommenda+ions:--------------------------------- -------------------------------------------------------------------------------•------ -----------------------------------------------------------I----------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------•-------------------------------•----------------•-------------------------------------------------- ---------------- ---- ----------)A--------------4------- --------- --------------------------Y- ------- PERMIT No.___"1_=�0.3____ ISSUED_J _:a _��.� __________(Date) FINAL INSPECTION BY:____ ______ _ Date--------------------- ------------- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES- 9-2M 9-50 W-1639