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3? . T APPLICATION FOR SANITATION PERMIT (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. JOB ADDRESS AND LOCATION____ . Owner`s Name-------- ,`- ------ ------------ -------------------- Address - - -_ - ----------------------------------------------------- Phone--:------- -- r ` f -- Address--------------- -----/ / • ' ' _ - ------------------------------------------------•-------•-------------------------------- _. --.-- Phone__._ ' Contractor's Name = r - -.- ;--`=�- �' ------`�-�- �` ------- `f; l -. _ ' - ----- Installation will serve: Residence 0 Apartment House ❑� Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ -1 Number of livingunits: ' ] Number of bedroom z. fes~ �- � � ❑ Number of baths Q Lot size---"-------------------------------•-----------------------' Water Supply: Public system 0 Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Q 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_________________Distance from foundation--------------------Material________________________-______________- ---. ❑ No. of compartments-------------------------Capacity-----------------------Size----------------------------•---Liquid depth---- -------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----_-_______________________________ , ❑ Size: Diameter--------------------------------------Depth----------------------------- Privy: Distance from nearest.well-------------------------------------------------Distance from nearest building----------______________________________- ❑ Distance to nearest lot line----------------------------------------------- Seepage Pit: Distance to nearest well-1 --__Distance from foundation_- __.Distance to nearest lot. line_ ______ Number of its-_ t^ " ,' } _, 1,h. © p' _ ...______ Lining material _ Size: Diameter__-- - -- -_}--- -�• ---- Disposal Field: Distance from nearest well fro --.Dep#h-_�"`__-_�_-_+---��---- , p _¢ g foundation_______ _ .__ _________Distance to nearest lot Jine---------------- `^ m_ ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material------------------_------Depth'of filter material-______________________ Remodeling and/or repairing1i TlEiif ----------------------- ---------------------------- -------------- ---------•---------------------•------------------------•-------- •------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin County ordinances, State laws, and rules andregulations of the San Joaquin Local Health District. __ _ x z� :—Z-111�_____________(Owner/and/or Contractor) (Signed) � t' ons, showinor g size of lot, location of system- in'relation- �-----------------------------------(Title)-_----`�_"_-`'--------------y------------------------ (Plot p g y lation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY- t APPLICATION ACCEPTED BY------------------------ ---------------- - DAT£--------- = fi> REVIEWED BY - �} ------ DATE------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------- - Alterationsand/or recommendations:------------------------------------------------------- ------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------•-----------------------------------------.---------------------•------------------.----------_------------ .: ---------------------------------------------------- ------•----------------------------------------------------•---------------------------------------------------------------- ------------------------- PERMIT No. 7 �`� `--- -- S�� + �[,f f' --- ISSUED -----.(Date) FINAL INSPECTION BY:------- ------------------------------------------------ 1 S sDate----------------�--—------- ---- - -----------�--•--------- ----•---•--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ,. ES-9-2M 9-50 W=1639 +