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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. l-L3 ,,]� --------------------------------------------------------------- - - -- --- - --------- JOB ADDRESS AND LO ATION-----fes----- /� --------- -------- Phone -------- ---------------------- Owner's Name---4/ - --- ------- - ---- ----- ------ ----- ---- - - - Address.-- ------- G?' .e��.e --- ------ ----------------------------------------------- --------------------------------------- ._ _ ' - Phoned Contractor's Name-- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of baths.] Lot size___ ----- Number of living units: ' � Number of bedrooms C�1 1 D-`0 OF Water Supply:I : Public system Community system ElPrivate F-1 Character of soil to a depth of 3 feet: Sand F-1Gravel F-1SandyLoam El Gay Loam ❑ Clay E] Adobe 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 welt__`— Distance from foundation----- Material---- ------------------------ -------- ----------------- No. of compartments — Capacity' Size Liquid depth__ # arest well_________________Distance from foundation_---_______-____-__.Lining material- _ _ -------------------------- ------- Cesspool: Distance from ne - i El Size: Diameter------------------------ ---------- p - Depth Privy: Distance from nearest weR-------------------------------------------------Distance from nearest building ❑ } ne------------------- ---- See a Pit: Distance to nearest well .�---�------Distance from fo dation____A�----Distance to nearest loft line__f_d- i Distance to nearest ,ot r f - Linin. material__�---------- Size: Diameter___- Depth ! ----------------- Number of psts________�_____ __ -- g Distance from foundation____f__2'------Distance to nearest lot line_-Z4........ k Disposal Field: Distance from nearest well________ __- l. �;-----------------Length of each line__-- -- --t- ----.Width of trench-_ - ----------- Number of lines--------- Type of filter material-�_.8�_ ------------ of filter material-_ ------- q '-Remodeiing and/or repairing. (describe):-------------------------------- --------------------------------------- ----------------- ------------------------------------------------------------------------------------------------------------------ - - --- ------------------------------------------------------ I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin County --------------------------------- fY r ordinances, State laws, and rules and regulations of the San Joaquin Local Health District.- i '0-a.'------------------------------------------------------------ �9Mrner-e*idfor Cantractor� 5i ned ---------------------- ---- k=-- ( g --- - - Title ------- --- "�'-------------------------- By---- --------- ---------- By:--- --------- (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 .ACCEPTED BY------------------- -------------------- DATE-----= APPLICATION .r ------ - DATE----------- ---------------------------------------------- REVIEWED BY-------------------------------------------------------------------------------------------- ------------ - ----- DATE--------------------- ------------=---------------------- BUILDING PERMIT--ISSUED--------------------------------------------------------------------- ----------------------- - Alterations and/or recommendations---------------------___________.________-._______- -------------------------- --------------------------------------------------- ----------- ---------------------------------------------------=------------ ---------- -------- -------------------- ----------- -- -- -- -- -------------------------------------------------- ------------------------ --------------------------------------------------------------------------------------------- ---- - ---- ---- ,f" Date FINAL INSPECTION BY-------- ---- ---------- - - ------ ----------------- PERMIT No!!5_- - ------ ISSUED-----_--- --Y � [ ------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639