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APPLICATION FOR SANITATION TION PERMIT (Complete in Duplicate) kALED Application is hereby made to the San Joaquin Local Heplth District for a permit to construct and install the work herein described. O This application is made in compliance with County I Nance No.,,549.1 JOB ADDRESS LOCATI r - C 'VI � -- � - Owner's Name___. -ALL.-------y - - -- ------------- _ w ,�t".✓Phone - - ------------ - - ------------------ - ------------------------------------------------------------------------------------------------------------------------------------- Contractor's Name_ ------------------- ------------------------------------------------------------------------------------- Phone_____________ Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court E] Motel ❑ Other ❑ Number of living units: umber of bedrooms [Z Number of baths 0 Lot size____ _•____X_ / � r Water Supply: Public system Communitysystem - ------------ Y ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ff-"*Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted 'f public seprer is available within 200 feet.) Septic nk: Distance from nearest wel__ _ f5istance fro foundation__ , No. of compartments__________ _ �--- .Mater'y�l_ ��a�-_�� "� ----------Capacity--- -----Size --x_ ��---Liquid depth------�'------------- Cesspool: Distance from nearest well_________________Distance from foundation ___.Lining material-------------------------------------- Privy: _____________________________ ___ ❑ Size: Diameter-------------------I-------------------Depth--------------------------------------------------- rivy: Distance from nearest well_____________________________________ ❑ Distance to nearest lot line______________________________________-___ Distance from nearest building-------------------------------------- '� Seepage Pit: Distance to nearest well----------------------Distance from foundation -------------------- to nearest lot line171 _________________ Dispos Field: Distance from nearest we material______________________Size: Diameter------------------------Depth___________________________r____ Number of its_________________ Lining U/_`. f.Distance from foundation__�_� Distance to nearest I t li e _��____-__ Number of lines_:_________ _____ � --�..-----I --- Length of each line___�j _____e Type of filter materi _ ' _ 5?"' ------------------------ Remodeling of trench------- _ -/-- -- -___ e th of filter material__________ ____ Remodeling and/or repairing (describe)______________________________ -------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------ ` -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- V V ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ----------- I hereby certify that I have prepared this application and that the work will be done in accordan-ce with-San-- -- Joaquin Cou-nfy ordinances, State I ws, and rul s and regulations of the San Joaquin Local Health District. r (Signed)----- L --- ------ _ ----- -------------------------------------------------- -------(Owner and/or Contractor) (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must bee efiled with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED Bl_1 DATE_ REVIEWED BY-------------------------------- BUILDING PERMIT ISSUED - DATE ------------------------------------------------------------------------------- A terations and/or recommendations____________________________________________ DATE_________ ------------------------------------------- ----------------------------------------------------- ------------- ------------------------------------ ----------------------------------------------------------- PERMIT N1---- ---f -- f j ---- ISSUED ------ I � -3 __(Date) FINAL INSPECTION BY:_______ _ l Date----•-------------------�..�_. . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W=1639 Stockton, California