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t 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 incompliance with Cou ty Ordinance No. 549. <br /> JOB ADDRESS AND LOCATION-- Q�!1 �--------------------------------------------------------- <br /> Owner's Name---- -- ---- ---- -------- Phone---................................ <br /> Address........ <br /> � .................. <br /> Contractor's Name--- -- /----- - " c, ------------------------- Phone-- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial x Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size-------------------------------------------------------------- <br /> Wafer Supply: Public system Community system ❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe x Hardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <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...../X_.._._..Material_..__.,-______________.__ .-.-----, ------- <br /> 1V No. of compartments_n_...51�-�!0Capacity.��dP___0+Aize_.j,n---S. .�.r.,Q-Liquid depth._....G6___r....... <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material_-_-.-.-_____---___-______,_-- <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- <br /> :Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_-_-__._________-________----..--___-----. <br /> ❑ Distance to nearest lot line•---------------------------•_--___-____________ <br /> Seepage Pit: Distance to nearest well______---------------Distance from foundation--------------------Distance to nearest lot line............ <br /> ❑ Number of pits......................Lining material-----------------------Size: Diameter-----__--•-_-_____..__-.Depth____•____________---_____--•__•. <br /> Dispos I Field: Distance from nearest well. ._..__.._.._.Distance from foundation _.,______Distance to nearest lot line __-___-_•__ <br /> Number of lines__---_--_ 0-----------Length of each line------�__l _________Width of trench____.___,2*y_"............. <br /> Type of filter material_._ �__1Q_A'__Depth of filter material......!r__'~_---_ <br /> Remodeling and/or repairing (describe)-------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---I----------------------------------------------------------------------------------------------------------- <br /> --•----------------------•--------•----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -•-------- --------------•----------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ............... <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, <br /> �State <br /> —laws, and rules and regulations of the San Joaquin Local Health District. <br /> •11_-_ <br /> (Signed)- --1... ----oDe - -- -- --- -----~=--- � -------------- or Contractor) <br /> ------------------------- <br /> By:------ - - -'... __a_�__^----------------------------------------------------------------(Title) -- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- -------- --------------------------------------------------- DATE---- ----- <br /> REVIEWEDBY--------------------------------------------------------------- ------ DATE---------- -- --------•-•••----- '� <br /> BUILDING PERMIT ISSUED----------------------------------------------------- -------- •---- DATE...................................................... <br /> Alterationsand/or recommendations:----------------------------------------------------------------------------------------------------•----------------------•----------------------------•------- <br /> -----------•-------•----------------------------------------------------------- --------------• -----------------------------------------------------------•------------------------------•-----------------.......... <br /> -------------------------------------------------•----------------------------------------------------------------------------------=--.-----------------------------------......--------------------------.--------- <br /> ----------------------------------------------------------------------•-------------.-------------------------------------------------------------------------------------------.------------------------------------------- <br /> ------------------------------------------------------------_- - <br /> - ---------------------------------------------------------- <br /> -------------------------------­........ <br /> PERMIT No......op ... ISSUED---- __. _. ..._1..._____._(Date) FINAL INSPECTION BY:-____V--- --_tit_�ir?--•--__ <br /> -~ 1 <br /> Date-------------_---_----�\C�`s I -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />