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' APPLICATION FOR SANITATION PERMIT 01 (Complete in Duplicate) * 6 Application is hereby rrtade to the San Joaquin Local Health District for e This application is made in compliance with County Ordinance No, 549. � permit to construct and install the work herein described, JOB ADDRESS AND LO TION.________ Owner's Name___.-__ _ --------------- ------------------------ Address - ---- --- ---- - -•----•-- ------------- ----- - --•- ' ------ ------------------ one = Contractor's N rt ------------- ame----- Installation will serve: Residence Apartment ~ `-� House - - �- ---- - -- --------------------------- - Phone_ ❑ Commercial ' ' C ❑ Trailer Court ❑ motel Number of living units: �. ❑ ❑ ,; Number of bedrooms Other Number of baths � � � .!— Water Supply. Publics stem Lot size______ Y Community system -- --�---�-�-� Character of soil to a depth of 3 feet: Sand ❑ Private ❑ ------------------- 3 --------- ------ e , ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay EJ Adobe TYPE OF INSTALLATION AND SPECIFICATIONS: 0 Hardpan Ej (No septic tank or cesspool permitted if public sewer is available within 200 f Septic Tank: Distance from nearest we])----------------- eet.) ❑ No. of compartments-__________ --- Distance from foLndation--------------------Material______- CapacitY --- - - -------------------------- Distance Distance from nearest well-----------------Distance from foundation e_"_____________.Li` Liquid depth-------------------------- Size_ ---------------__" " ❑ Size: Diameter____----------------------------------- Depth----------------------------- --- _ nmg material-------------------------------- Privy: ______ + Distance from nearest well ""�""--"- ❑ ................. ................ from nearest building Distance to nearest lot line_____________"_" Seepage Pit: ------------------------------ --------------------- istance to nearest well____--___4�-_Distance from foundation---- Number of pits_________ --------- Di tanc to nearest lot..4ne _ "O ' Disposal Field: I--------""Lining material.__/ _gyp - Distance from nearest well----------------- U110 -Size: Diameter____._ Depth " __Disfiance from foundation_________ 13 Number of lines____ ____________ -_-_Distance to nearest lot line___-____ ---- ----""--Length of each line ----- of fiifer material----------------- --- -Width of french-------------------------------------------- Remodeling Depth of filter material_____------------------ s _____ _____ _ Remodeling and/or repairing [ escr'be):" "-""" / a -" - - -------- ----- -- ----------------- �. -------------------------------------------------------------------------- --- -- I hereby certify hat�!^I a a prepardWfhis application and that the work will be done in accordance ordinanc , State J s, a d rules an regulations of the San Joaquin " Local Health District, with San Joaquin County (Signed)_-_ , _"_-- -----•-- ----------- - - ----- y- ---------- ------------------ - ----(Owner and/o' r Contractor)------------ --- -- ------- - (Title)to wells, buildings, (Plot sow+rig size'of lot, location ofsyste in-'re-la ------- etc., must be filed with this application). ) OR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY _"_ REVIEWEDBY----------- ----- ---- ----------------------------------------------------------------- DATE_.__ ------( __ 2 BUILDING PERMIT ISSUED ----- -------------------------------------------------------------- ----- --- -- ------------ - ATE---------------- ---- Alterations and/or recommendafions:-------__"_-- ------ DATE_" ------------ --------------------------- --------------- ---------------------------- ..�y. _______________________________________________ _______________________________„________.________.___________.________-___________________._____-__________-__________ __-__- __ __ _ -'------------------.----- "-----•----------- - -_ PERMIT N ___••------------ --- ------ - •---- ISSUED------------ --.�--� --.Y� ---------------- Date + , -.(Date) FINAL INSPECTION BY:_--_-__"-- -------------------------------------- Date----------------- _ S( /75— SAN JOAQUIN LOCAL HEALTH DISTRICT 3 130 South American Street ES-9-2M 9-50 W-1639 Stockton, California