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APPLICATION FOR SANITATION PERMIT I (Co plat m Duplica#e) 0 s 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 o. 549. JOB ADDRESS ND CATI . -- --------------------------- ---------- ----------------------------------------- --- Owner's Name =' ''�„- --- - �------ -------------------------------------------------------- Phone__ �_�f 7 Address----------- . --- . --- - - a Contractor's Name- _-- -! f Installation will serve: Residence tment House ❑ ommercial ❑ Trailer Court ❑/M tel E] Othe ❑ ` Number of living units: [KNumber of bedrooms I Number baths [jJ Lot size..... �__x_��V_ Water Supply: Public system ❑ Community system ❑ Private Character of soil to a depth of 3 feet: Sand Gravel Sand Loam Cla Loam Clay Adobe Hard an P ❑ ❑ Y ❑ Y ❑ Y ❑ p ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet.) / CC Septic ank: Distance from nearest well__�C�__._Distance from foundation..._4-4-_ .Mat i I__ ... py_- [ No. of compartments_____________�._____Capacity__Q__l _ ^Size:_ ., _ _ _ iquid depth_____________-____:_ Cesspool: Distance from nearest well------------_----Distance from fpuridan--------------------Lining material------------------------------------- ❑ Size: Diameter-----_------ - ------------------Depth-----------------'=---------!'--------------------- � Privy: Distance from nearest well--------------_----------------------------------Distjnce from nearest building______-._._-__-__-_________-___-.____.__. ❑ Distance to nearest lot line__________-_________________________________-_ Seepage Pit: Distance to nearest well----r,Y ...________Dupe from foundation _`�---- ____.__.Distance to nearest lot line ❑ Nulwpber .of,pits-- Li ing tma t _^--------- ---- p i De th-._ ._---_ ..-_ ',_Dispos Field: Distance rom nearest well---- ___-.Distance from foundatio _.Distance to nearest lot li � - f- Number of lines____________ _ __ l Length of each line___f__ _ ____ ________Width of trench_ ____%�t__ ____.___ .-------- Type of filter mate ria l _1_'�._ epth-0f filter materia___,____�__ _ ___ 1� Remodeling and/or repairing (describe):-_--A--_ w _la_ ______ �- ?17 - ---------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=--------------- -------------------------------------------------------------------------------------------------------------------------------=------------------------------------------------------------------------------------------ -------------------------- ------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sfatk laws, and jules and regulatio of the San Joaquin Local Health District. fl (Si ned Owner and/or Contractor 9 ) � -' ----- -- --- ------------ -- -- - - --- ------- ( / ) By: ------------------------------- (rile) (Plot plans, showing size of lot, loc tion of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY �r APPLICATION ACCEPTED BY------------ --- --------- -------------------------------------------------- ------ DATE 1 ------------------- ---------- --- REVIEWEDBY------------------------------------------------------------------------------------ ---------------------------------------- DATE---------- . BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------=------ DATE------------------j------------------------- Alterations and/or recommendations-------------------------------------------------------------------------------------------------------------------------------------- ....................I--------------------------------------------------------------------------------------------------------------------------------- ........---------------7--- -• ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- ----- ------------------ ------ ---------------------- !- - I--------" ------------------- --- - - -------------------- ------ ------- --- PERMIT No_____________14____-_ ISSUED __-�__ �__...__.---__._____-•___(Date) FINAL INSPECTION BY:_._______._ _ ___ Date-------------------------- - ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639