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�[ �o APPLICATION FOR SANITATION PERIvtl7 (Complete in Duplicate) 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 ---------- a ---- �iC �-�L.� , Owner's Name -- ------------ ---- - -------------- Phone ---------------------------- Address ... -------- ---- ---- Address--- ------------------ -----------------% 3 ----------------------------------------------------- Contractor's Name ----------------------------------------------------------- -------------------------------------------------------------------•------- Phone. ------- ---- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other" Lffij" :> Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size___________________________ Water Supply: Public system ❑ Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ . Sandy- Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑`; TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________ Distance from foundation ________.__________- Material ----------- --------------------------------- 171 _--_-_-__-,-____:_ _____❑ No. of compartments -------------------------- Capacity ----------------------- Size -------------------------------- Liquid depth ---------_--------------- Cesspool: - ------- -------Cesspool: Distance from nearest well ----------------- Distance from foundation------------ .------- Lining material-------------------------------------- ❑ Size: Diameter-------------------------------------Depth--------------------------------------------------- Privy: , Distance from nearest well_____ i_$Q______ ________ Distance from nearest building_-__-____. Distance to nearest lot line__________________�_Q----------------------- 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 ----------- -...... Distance 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 ___-________------ -__ Re odeling ancVQr repairi (describe): ------- ffilk--- -----b r--------- ly ` ------------- % - ____________________________________________________________________________________________________ ________________________________----------------------r--------------------------------------- �_ =' __- I , ` hereby certi hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State s, and rules and regulations of the San Joaquin Local Health District. (Signed) -- ....... .__(Owner and/or Contractor) By: --------------------------- --•-------------------------------------------------------------- --------------------------------------- (rifle) ---------------------------------------- -------------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., mush be filed with this application). n / FRPDEPARTMENT USE ONLY APPLICATION ACCEPTED BY-_---___ REVIEWED BY ------------------------------------ BUILDING PERMIT ISSUED _____________. PERMIT E -9-2M 9-50 W=1639 L, ------- -•---•---------•- 1- 1-1 . .. ,. - -------- - ------ DATE-------------'- -------------------------- DATE ---- ......... r w- Date-............................... -................................. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California