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i APPLICATION FOR SANITATION PERMIT (, �rll (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--•��. ----------------------------------------------- Phone-- -- ----------------------- Address- I __ _� ----------------------------------------------- --------------------------------------------- Contractor's Name- tA------- " '`= ------------------------------------------------------- Phone__ °`_ Installation will serve:. Residence „ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: [I Number of bedrooms J2e Number of baths t Lot size___ �if--I Water Supply: Public system;K Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobel 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 f dation-__-;Z4______-Distance to"nearest lot line-- A --------------- Number. _- _ __ Number.of pits--------/-____-_--___Lining material___-�__'_ -Size: Diameter_____ __ Depth____ _''d__ _________________ a , Disposal Field: Distance from nearest well-----------------Distance from foundation_______________-___Distance to nearest lot line_________________ Number of lines----------------------------------Length of each line------------------------------Width of trench--------------------- ------------- Type of filter material_________________________Depth of filter,material___-___--_____-_-_-____ Remodeling and/or repairing (describe)-------------------------------------------------------------------------------------------------------- ---------------------------------------------------------- g--------------------------------------------------------------------------------------------------------------------------------- -------------- I 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 and regulations of the San Joaquin Local Health District. (Signed)--- t --�"r- Q_��•3-------- ------------------- - - - ----------- ---------(tea/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---- -------r ------------------------------------------------- DATE------ _n- REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE---------------------- ------------------------- ------------- ---------------------- - UILDING PERMIT ISSUED-------------------------------------------------------------- ---------------------:---------------- DATE----------------------------- - ---------------------------- Alterations and/or recommendations:------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------•---------••------------------------------------------------------------- ------------------•--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------•----------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- -- -------------------------------------------------------------------------------------I -----------------------------------•----------------------- PERMIT No.�-V_7------- ` vi-- ----- ISSUED-------l-"_"� --s/-----------fDate# FINAL INSPECTION BY-------- - ---- - ------�--------------- --------- Date-------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639