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APPLICATION FOR SANITATION PER MIT 1� (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_ __ _ _"_ I A Owner's Name------- "' /d` g ----------•-------- --------------------------------------------- Address --------------------------------------------------- -----------•------------- Phone------------------------------------ ............................-------------------------------- ----------------------------------------------------------- --------------------------------------------- Contractor's Name------------------------ ----------------------------------- Phone - ------ --- - ---- ------------------------------- ------------- nstallation will serve: Residence Apartment House E] Commercial El Trailer Court E] Motel E] Other Q - Number of living units: Number of bedrooms ❑ Number of baths ❑ Lot size--___ J _ _____= ' c� ��" - ---------------------- 1 Water Supply: Public system ❑ Community system ❑ Private Lrl 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-__ Cw --- --.Material------------------a4C-------�--------• No. of compartments-------------�-------Capacity-------jc»------Size__-_S'` t�•_vLiquid depth------J7?-__________ Cesspool: Distance from nearest well____ ___Distance from foundation_-_--_-__-_________-Lining material___-___-_____--_-_-___----_______-_-_. Size: Diameter--------------------------------------Depth---------------------------------------------------- .S 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_______-______--_ fi ❑ Number of pits Lini.? material-----------------------Size: Diameetep,------------_--_---.Depth----- --------------------------- Disposal Field: Distance from nearest well--------7--------Distance from foundation___________________Distance to nearest lot line__a1?______ ( Number of lines_______________ _______ ______Length of each line -�_ �, L y-------Width of trench_______-____? `! T e of filter material___I. /`' p Type r____De th of filter material-_---____ -____:__• Remodeling and/or repairing (describe):--------------------------------- ----------------------------------------------------- ------------------------------------ ------------------------------------- --------------------------------•---------- ----------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the=San Joaquin Local Health District. (Signed) --• ---------------------------------------------------------------(Owner and/or Contractor) (PlotBy: --------------------------------------------------------------------------------------- Title ___________ _______ 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------------------- REVIEWED ---------------- a DATE------ ---------------------- ! REVIEWED BY _�--- + -------------- ------- ------------ ----- ---- - --- ----- ------ DATE-----------: s BUILDING PERMIT ISSUED---------- -------------------------------- - DATE----------------------------------------------------------- Alterations and/or recommendations____________________ ------------------------------------------------------------- ----------------------------------------------------------------------- -------- --------------------------------------------------------------------- -----------------------------------e2_ 5 PERMIT No.�Q____�______ ISSUED__-` � _^'[_---__(Date) FINAL INSPECTION BY:--_-____-- Date -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W=1639 Stockton, California