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APPLICATION FOR SANITATION- PERMIT q (Complete in Duplicate) 1 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---------- -� ______�____-7__-______r. ____ _ --- - •-------------------- Owner's Name .• _ t' ':'r---------- - --- ------ --"-----------------------------------. Phone 's1 ` � Addressa w ' ' ----- -----=--•------------------------- - ----- --------- -------- �. ------ --- Contractor's Name----------------- __;5 � - --`-{ - - r aPhone Installation will serve: Residence Apartment House '0 C mmercial F1 Trailer Court El Motel E] Other E] 1 Number of living units: er of bedrooms� Number of baths of size_____ -0--- J-- Z---C,�------------- Water Supply: Public system Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand-E] Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobeardpan ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: `! (No septic tank or cesspool permitted if public sewer is available within 200 feet.) v 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--------------------------------------- ElSize: Diameter--------------------------------------Depth--------•------------------------------------------ Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_________________________________________. ❑ Distance to nearest lot line________ -------------------------------------- % 1 Seepage Pit: Distance to nearest well------ o *f unda ion__/________.Dist rice to nearest lot -------- Number of pits..... _Lining materiaiP��e: Diameter_____��___..___--Depth_____ ________________ Disposal Field: Distance from nearest well------------------ 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):--------- �� "' _ .y.0I!___ , -----•-------------------------------------------------------------------------------------------------------------- ----------� ------- ------------•---------------------------------------------•---------------------- ------------------------'---------------------- ---------------------------------.------------------------------------------------------------------------------------------------------------------------------------------.. --- --- ----- - - - ---------------------------------------------------------------------------------------------------------------------------------------------I------------------------- 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. .. �. d -- - -- ;-- 1 - Owner and/or Contractor (Signed)- ---- - s .r. By:---- f --- ------ -------------------------------------------------------------------(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 - - --- ------ DATE r REVIEWED BY --------------------------------------- DATE---------------- - � -- ------------------- BUILDING PERMIT ISSUED------------- ---------- ---- --- DATE------------------------------------------------------------ Alterations and/or recommendations:-_-_-- -- - __,. s __ _':_-- _-- :--------------- ------------------T------------------- ----------- ------------------------- --------------------------------------------------------------- � � I's-- c es ---—-- -- ` � /��.� �-� � � t, �:_ C --------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------- PERMIT No.__`'�_____Y�___ ____ ISSUED____�_''r_7 `� ______.(Date) FINAL INSPECTION BY:__-----��-W` ._-�!`___ �-------------------------------- V ______ __--- Date ----- ----------------------------------------- SAN �----� ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9--2M 9.50 W-1639 d