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APPLICATION FOR SANITATION PERMIT -3 `. (Complete in Duplicate) Ap applicafion is made in compliance with County Ordinance No. 549.plication is hereby made to the San Joaquin Local Health Disfricf for a permit to construct Thiand ins#all the work s herein described. JOB ADDRESS AN,D L.00ATION___ � � 1 - - --- ------�;C- - -�----`-1 -- __- _____` Owner's Name_____ " / ----- - -------------- -- 4/x7 - Phone .__ Address----------------- -----.._r_ �'/.� - - Contractor's Name----- --------------------------------------------------------------------------------------------- ,�,. _ � ��--- - �----------------------------- _ __ -- --- ----------- - -------------------------------------- ------ Phone_'- `� 7 � Installation will serve: Residence Apartmenf House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 1h Number of bedrooms '® Number of bafhs 0 Lot size________ _______A_ Wafer Supply: publics stem �" Y yX Community system ❑ Private / Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clayq TYPE OF INSTALLATION AND SPECIFICATIONS: ❑ dobeHardpan E'] ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank; Distance from nearest well-----------------,Distance from foundation_____________"""""_-Material--------------------------------------------- Cesspool: ______""-_""_ ❑ No. of compartments-------------------------Capacity---- ------------------------------- Cess oof: Size --------------------•--------Liquid depth------------- ❑p Distance from nearest well__"______________Distance from foundation--------------------Lining material________________"___" Size: Diameter--------------- ---------------------Depth-------------- ----------- Privy: Distance from nearest well__________________________ ____ _ Distance from nearest buildin u ❑ Distance to nearest lot line--- --------------- ---- g ----- ------ --------------------- .- -------------------- - ----- `par a Pit: Distance to nearest w, II__`"�"�""�"`Distance from foundation___ 1 r Number of its_______ A Distance to nearest lot Gne �___""-• e _ P911 p ----_"--Lining material' __ Disposal Field: Distance from nearest — Size: Diameter_____c '!____-_.De Depth- _ ___-__.Distance from foundation -��,5""- __.Distance to nearest lot line_____.�e�'•""_ K' Number of lines___________, --•------- Length of each line-------- 1 -------------Width of trench----?-Y_�' Type of filter material= '" . _Depth of filter material_____./ �^ s:� _. Remodeling and/or repairing (describe)_______________'"_____ n ------------------- ! ------------------------------- --------------------------------------------------------------------=---- �. -------------- ---------------------------------------------------- hereby certify that I haveAprepared 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)--•- --` il�� -_ ' -4 By:--- ------------------------------------------------------ -------- w= / (Owarersand/or Contractor) _-C --------------- ----- - ------(Title)_C= (Plot plans, showing size of lot, location of system in relation to wells, buildings, a+c., must be filed with this application). FOR DEPARTMENT USE ONLY { APPLICATION ACCEPTED BY..........._`___ _ 1"-" -" REVIEWED BY --------------------- DATE------ ---- - - ------- BUILDING PERMIT ISSUED-------------------------------------------------------------- ". DATE -----------'' ------------------------------------ - ------------------------ -- DATE------------------------------------------------------------- fions:and/or recommends#ions:________""-"_ -- """--"--"---"- --"-"-" �----"" -"--- ---------- -------------------------------------------------------•---------------•-------- ----------------- - --------- -------------------------------------------------------------------------- ---------------------------------------------------------------------------------- ,('�-------- -------- ;;; - - --- -------------------------------------------------------------------- ---- - b _r/ J(Date) FINAL INSPENBY: Date - --------------- -•----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 1 ES-9-2M 9-50 W-1539 Stockton, California