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APPLICATION FOR SANITATION PERMIT (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__________ `7` _ O I N wners ame ---------------------------------------------------------------------------------- ------------------ Ph one ------------------------------------ ,-� , . Addressp � ---------------------------------------------------------------------------------------------------------------- Contractor's Name-------------------- F� -------------------- !---------------------- Phone ---�--�--� ---= Installation will serve: Residence [►' Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: '❑ Number of bedrooms L2— Number of baths ❑ Lot size ---- z7OQ__x___ _________________________ Water Supply: Public system V Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam n Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi . ank: Distance from nearest well_________________ Distance from foundation -------------------- Material ------------------------------------------------- No. of compartments Capacity ------Size-----------------------------_..Li depth -------------------------- Liquid de f, P p tY----------------- q p Cesspool: Distance from nearest well ----------------- Distance from foundation -------------------- Lining material -------------------------------------- ElSize: Diameter------------------ ------------------- Depth ------------------------------ --------------------- Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building ------------------------------------------ El Distance to nearest lot line________________________________________________ ,*Seepage Pit: Distance to nearest well ---------------------- Distance from foundation ---------------- -__Distance to nearest lot line_________________ ❑ Number of pits ---------------------- Lining material ------------------ ----.Size: Diameter ------------------------ Dept h----._-.------------------_------ Dis I 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 ----------------------- 'Remodeling and/or repairing (describe):--- ----------- 1 Ord - ---- - -�---------- J - --------------------------------------------- S--�-----------------------------------=��f-- ----------------------- -- ------------ - --------------------------------- --------------------- ---------------------------:-------------------------------------------------------------------------------- I herebycertify 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) ----------------- - ------------------------------------------------------------ar`Confractor) BY=----�-t-----.:� -!--jam--- �-----------------------------------------------------------------(Title)---------------------- ------ ------- --- -------- (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be fled with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ _%J �' i✓a--------- DATE ---- ��---- �.S----------- - ------------ ------------------------ REVIEWED BY------------------------------------ ---------- 7---f`'---------------------------------------------------------------- DATE ----------b-"--- "- � ---------- -------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------- ---------------------- Alterations and/or recommendations----------------------------------------------------------•----------------------------------------------------------------------------------------------------- ---------------------------------------------- ---------------------------------------------------------------- PERMIT No.l.�,-__.---------- ISSUED---O_"'-�t--'-^----------- (Date) FINAL INSPECTION BY:------ ---.-_- ------------------------------------- Date ------------- Date-------------� �� ---- SAN JOAQUIN LOCAL HEALTH,DISTRICT 130 South American Street Stockton, California ES -9-2M 9-50 Wd 639