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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. <br /> JOB ADDRESS AN LOCATION_ <br /> i �_- -_-- -------------=--_----------------------------------------------------------- <br /> .- ------- �_ya ------------------------------------ Phone <br /> Owner's Name " ------------------- ----------------------------- <br /> Address--_. <br /> ---------------•------------ <br /> Address--_.- G • l= - - - ----- -------- , i <br /> tmQ ? I -- - ------------------- -- - - ---• ------ Phone <br /> Contractor's Name-._- - ----- ---_ `-- <br /> •Installation will serve: Residence% Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: Number of bedrooms ITNumber of baths I/ Lot size____. .... O <br /> ----------------- <br /> Water Supply: Public system ❑ Community system [I Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam El Clay Loam 11 Clay ❑ Adobe Hardpan F] <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: x <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_________________Distance from foundation-------------------.Material------------------------------------------------- <br /> ❑ No. of compartments-----------------------•-Capacity--------------- ------Size----------------•---------------Liquid depth-------------------------- <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-------------------------------------- <br /> F1Size: Diameter--------------------------------------Depth---------------------------------------------------- <br /> Privy: <br /> -------------------- -----------------------------Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ <br /> F1 Distance to nearest lot line------------------------------------------------ <br /> est well---------------------- from foundation-------------------- to nearest lot line----------------- <br /> Seepage Pit: Distance to near❑ Number of pits----------------------Lining material-.---------------------Size: Diameter_ Depth <br /> f <br /> ____. <br /> ��___ __-.__ <br /> Disposal Field: Distance from nearest well____{^f��_.Distance from foundation________ __ ___Distance to nearest lot line ne,__ - <br /> Number of lines-------------�•-----------------Length of each-line-------- -----------Width of french------2-fI---------------------- <br /> Type of filter material_ l'_'_' _____Depth of filter material__--_ ------------ <br /> ------- <br /> 4 <br /> Remodel' g and/or repairing (describe):________ _ <br /> --- <br /> - _.__.._.. ----.._. <br /> [ ----------------------------------- <br /> ------------------------------------------------------------ -------- ---------------------------------------------------------------------------------------- •---••-------•------------------------ <br /> hereby certify that I have prepared this application and that the work will be done in accordance.with San Joaquin County <br /> t ordinances, a law and rules and regulations of the San Joaquin Local Health District. <br /> a <br /> ' -- c�,,•,.e----------------------------------------------- <br /> (Signed - {Owner and/or Contractor) <br /> R (Tle) <br /> Be--- -----'•-- -•rte--- -------------=-- -------------------------------------------------------------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must b file with this application). <br /> FOR DEPARTMENT USE ONLY <br /> DATE------- ------------------- ------------ <br /> 16 - d-7 <br /> `6 d 7 4-` <br /> APPLICATION ACCEPTED BY-------------------- -----fl.- j-::- ------------- ------------ ------------ --------- <br /> ",�' --------- -------------------------------- DATE_------------- <br /> REVIEWEDBY----------------------------------------- -- -------- - ---------- ------------ - - <br /> BUILDING PERMIT ISSUED----------------------------------- ------------ ------------- ------------ ---------- ------ <br /> -- DATE------------------------------------------------------------- <br /> Alterations and/or recommendations------------------------------------- ------------------------------------------------------ <br /> --------------------------------------------- <br /> ( -----------------------------------•-------------•---------------------------------------•------------•------------•--------•----------------------•------ <br /> -----•-------------------- -------•------------•------------------- ----- -------------------------------------------•------------•-----------•--------•-------- <br /> PERMIT No----------- ------------- ISSUED------------------------------------------(Date) FINAL INSPECTION SY:---;0-----------I------ <br /> ----------------- <br /> 9±------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> I Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />