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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 scribed. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION____________ _ _ " ' - ----------- � ` ` '' " -- ----------- -------------------------- Owner's Name---------------- ---!---Z----------•ter- _ __%,,;.:_.. .-- ------ --- ------ ----------------------------------------------------- Phone------------------------------------ -------------------- --- Address ' --------------------Contractor's Name---------------- _ , 1 �.,._- - ---- -------- .. ----------------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment I se ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: Y1 Number of bedrooms W Number of baths Lot size________ Water Supply: Public system ❑ Community system ❑ Private A Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑] TYPE OF INSTALLATION AND SPECIFICATIONS: septic tank cesspool slpermitted tF public sewer l l2Ufe . Dtance fromfoundato . aSe tic TankDistance from nearest eI _ ----__.Material------- - - ---- --No. of compartments--------------------------Ca Capacity ------Size---- ------------------------ 1 Liquid depth-- --- e th____- -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----------------------Distance from foundation-------.-----------.Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter--------_-------------_.Depth--------------------------------- Disposal Field: Distance from nearest well-__-10_ ___.Distance from foundation____lS_______-gistance to nearest lot 1ine_,___40__'f Number of lines_______________� _Length of each line__________r' 3�7 Width of tench___.,_ ____`_______-_.._-_ Type of filter materialIZ,-- 1► r ,Depth of filter material------/-{ ..______ Remodeling and/or repairing (describe).-------- -- _----__-- a"� •; �• = GXA a • . r: . _ r-------------------------------- '-------------------�----''---==----'-------'--------I-__----------- -A-----------0-- � ----------- ----- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- hereby certify that I have p pared this application and that the work will be done in accordance with San Joaquin County ordinances, State I aryl rule M d regulations of the San Joaquin Local Health District. -01 (Signed)---------- ----- --, ------------------ -- _______(Owner and/or Contractor) -------------- ------------------------------------------ By:. i 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--------------- � !f DATE ' REVIEWED BY -------------=- ------------------ ------- DATE-_- = - ------------------------------ - - ------------------------ BUILDING PERMIT ISSUED--------------------------------- -- ------- DATE-------------------------------- -- ---------------------------------------------------- --------------------------- A terations and/or recommendations:-------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------I--------------------- ------------------------- ---rr- - ------ -- ---- --------------------------------------------------------- - �`! _- ---- ISSUED-----��----- s _...-----_-- Date FINAL INSPECTION BY-------- ------- j PERMIT No._ ---- �l . :.; Date------------------ ------------ - SAN JOAQUIN LOCAL HEALTH DISTRICT I30 South American Street E5-9-2M 9-50 W-1639 Stockton, California