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1 APPLICATION FOR SANITATION PERMIT z� (Complete in Duplicate) r � Application is hereby made to the San Joaquin Local Health District for a permit to construct and install +he work herein described. This application is made in compliance with Courcy Ordinance No. 549. JOB ADDRESS AND LOCATION " --------------------------------- Owner's l3=� C.-r{`- -` ` - i»-----------------�G w _= F � . Owner's Name--- Phone- " f Address7-f i f `{--- ----------------------------------------------------------------------------------------------------------------- -- Contractor's Name-------------------------------------------------- -- ---- ---- -------------------- Phone----------------------------------- Installation will serve: Residence [ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms 7 Number of baths ❑ Lot size--------- _3za---x/n-b---------------- Water Supply: Public system ❑ Communi+y system ❑ Private [Y Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [ff Clay ❑ Adobe ❑ Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septid tank or cesspool permitted if public sewer,is available within 200 feet.) Septic Tank: Distance from nearest well----- /__Distance from foundation____----' ______..Material_-___ ---- -----------------------------WOE IN No. of compartments---------------------Capacity--------------------- Size--------------------------Liquid depth--------------- --------- Cesspool: Distance from nearest well-----------------Distance from foundation..------------------Lining material--__ __....______-____________. ❑ Size: Diameter--------------------------------------Dept h---------------------------------------- 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------------------------7------- i Disposal Field: Distance from nearest well-----------------Distance from foundation----- --------------Distance to nearest lot line_--�_________ Number of lines_______-_�-____ _. Length of each line--------V-d_ _ ______________Width of trench -__/,Y�..._ __________________ Type of filter material___---_---- _ Dep+h of filter material-_-___!p-._____-_ Remodeling and/or repairing (describe):---------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- ------------------------------------------- ------------------------------------------------- ------------------------------------------- ------------------------------------------------------------ I hereby cert' y fhq I have prepared this a lice}ion and that the work will be done in accordance with Sen Joaquin County ordinances, Stat arvs, nd ru s and r gulati s f the,San Joaquin Local Health District. [Signed) --- ----------- - -------- (Owner and/or Contractor) ---------------- By:-------------------------------�1�cafion ------------------------- -- . . . -- - (Title)---- ------------ --------------------- (Plot plans, showing size of lot of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ -- ` _ DATE REVIEWED --- ---------_------____-- �- REVIEWEDBY--------------------------------- = ?'------------------------------------------- DATE------------------------------ -'rte--------------------- BUILDING ------- ---- ---- BUILDING PERMIT ISSUED ------------------------------------------------------------------------------------- DATE----------- ------------------------------------------------ Alterations and/or recommendations----------------- ------------------------- --------------- ----------------------------------------------------------------- -------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- ------- -------------- - -- -- - ] -.------------------------------------------------�-----3.- ----[--------------------------------------- '� '} �_ �___ (Date FINAL INSPECTION BY:_--_- -------- :. _' -- PERMIT PJo._._-__-- -----------__-- ISSUED... .. -- �, Date-------------------------------------------------------- ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 7tl T i3- Stockton, California ES-9-2M 9-50 W 1639