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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No 549 <br /> JOB ADDRESS AND LOCATION---- --- ---- -- �.? ----------------------------------------------------- <br /> Owner's Name- ------- -------------- ------------------------------------------------------ Phone----------------------------------- <br /> Address------- <br /> ----------Address------- -----•- <br /> Contractor's Name-- -% - t---- -- --- -------------------------------------------------------------- Phone ` - <br /> Installation will serve: Residence x Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: Number of bedrooms Number of baths I Lot size..... a _________________ <br /> Water Supply: Public system Community system ❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe x Hardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �. <br /> Septic ank: Distance from nearest well_-'""'-"'.Distance from foundation____ Material_-__ ______________ <br /> No. of compartments--------- ------------CaacitY---- . -. - ---f--Liquid depth--SA--'--*- <br /> --------- <br /> Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material_____________-_____________-_________. <br /> ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- <br /> ",Privy: Distance from nearest well--------------------______-----------------------Distance from.nearest building---------._____________---_____________:_. <br /> ❑ Distance to nearest lot line------------------------------------------------ <br /> Se p <br /> _______________________________________________Seepa a Pit: Distance to nearest well_____—_____:_____.Distancefi�o�m foundation-----42 _.Distance to nearest lot line---/97__� <br /> Number of pits_______/__________Lining material.-_G" __ ,Size: Diameter_____,W._��__.Depth--------JW_�t------------ <br /> Disposal Field: Distance from nearest well-___---_____.Distance from foundation...../_2_ <br /> .....Distance to nearest lot line__ _____ <br /> Number of lines______________ th of each <br /> g_ __ en line___ Width of french......$_ !!_____________ <br /> r �i► • + <br /> Type of filter material_--, epth of filter material_---- -ie-----v---_- <br /> Remodelingand/or repairing (describe):-----------------------------•----------------------------------------------------------------'----------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------------------------- <br /> -------••---•-------------------•-----•---•--•-••----------•----•------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> I hereby certify that I have prepared this application and that the.work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. <br /> p ' <br /> (Signed)- l / '�' CllRlsl-8 /or Contractor) <br /> BY: -1 ; 'f--- ~` - --------------------------------------------------------(Title)._ ------------ ------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------------- l-� ___ r ------------------------------------------------------ DATE------tom .. <br /> REVIEWED BY----------------------------------- <br /> ----------------------- <br /> -------✓------------------------------------------------- --- DATE-------- ----------------------- <br /> BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------ <br /> Alterationsand/or recommendations:------------------------------------------------------------------------------------------------•----------------------•--------------------------------- <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------------•------- <br /> ----------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------- <br /> --------------------------------------------------------------------------------•-----------------------------------------------------------------------•----------------•-------------------------------------------------- <br /> ---------------------------------------------------------------- -------------- --------------------------------------------------------------­----------------------------............. <br /> PERMIT Nol�-577 ___ ISSUED----- .__ _ _-__J_74---(Date) FINAL INSPECTION BY:.__________uj_0___�----_---_----_,_-_.-• <br /> �^ r- rf•- <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W=1639 <br />