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APPLICATION FOR SANITATION PERMIT 7 Y (Complete in Duplicate) 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. .ST - 1 +/�jL) 7 JOB ADDRESS A�LOCATIO _____--3Y y�// - - - ----------¢`- / � u.. 4 ------------------- Owner's Name____ ___ __ ___ -------------- Phone--------------------- ----- -------------------------------------------------------- Address ---/------ ------------- ------- - -- --- ------------------------- ontractor's Name____________________ ----••--- --------------------------------------- ---- Phone--- ------------------------------------ ----- ----- Installation will serve: Residence ❑ partment House ❑ Commercial ❑ Trailer rt ElElfihe Motel gr Number of living units;e�Number of bedrooms-P- Number ofCat s. Lot size__! Water Supply: Public system ❑ Community system E] Private A Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobev 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- j----Distance fr m f undation_____to----- I- No. of compartments___-__''-- - ----------------Capacity - -��---VS-101 e---------- L�uid depth- ---- -�--Cesspool: Distance from nearest we11_________________Distance from fou ___---________"____.Lining material_________-_-___________-_.__.._____.� (1 ❑ Size: 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________._______! ❑ Number of pits----------------------Linin aterial-------"__--_----------Size: Diameter-------•-------------_ Disal Field: Distance from nearest well__ ___________Distance from foundati n_h_ - _______Distance to nearest lot.Iinev,_ /7t�__'- y Number of lines------------I________________ Length of each line ---- tr_Width of trench---- �----------------- Type of filter material--,5-j_ __ ___ ._Depth of filter material________ - ----__ Remodeling and/or repairing (describe}:_--___- - ---------------------------------------- r I I- ------ __: T ------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------- -------------------------------------------- --------------------------- -- -- -- ------------------------------------------� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County7,11 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. f �' ` 11 (Signed)------- 1�_----- �-. - c ---------------------------(Owner and/or Contractor) BY-----------------------------------------------------------------------------------------------------------------------------------(Title)------------------------------------------------ (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------ --------- DATE_ REVIEWED BY ------ _.. DATE----- --- --------------------------- BUILDING PERMIT ISSUED-------------------------------------- -----" -------------------------------------- -------------------- DATE - ------------------ terations and/or recommendations_ - - -- - - ---------------------------------------- -------------------------------------------------------------------------- -------------------------------------------------------------------------------------- ----------------- ----- PERMIT N .-- -----""- Y ISSUED---------- ---- - 3-_-- (pate) FINAL INSPECTION BY:___-- ----------- _ �yy -- Date---------- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street E5-9-2M 9-50 W-1639 Stockton, California