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, - -- pa� � s 6 APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) A lication is hereb made to the San Joa uin Local Health District for a permit to construct and install the work herein described. Th is application is made in compliance withCountyOrdinance No. 549. 1 JOB ADDRESS AND LOCATION-------- -1-- - a ------(>-A-m---------------------------------------------------------------------------------- 1 * _-- Owner's Name----------- D-4-�'---------j3--&-C-4-0- 11- ------- Address------------------------ ----._$-r�__v-70--------- V--�. - 7 = qq 1 Contractor's Name-------------- --k- - U-------------------------------------------------------- Phone = F Installation will serve: Residence ❑ Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �Y' t yy// d Number of living units-3 Number of bedrooms Number of baths Lot size----4ro- ---_-.hl_ c7------------------- Water ----- --------Water Supply: Public system ff Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay❑ Adobe;x 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____-_ .------_____.Material____--_-____-_____________________----__._- ❑ No. of compartments--------------------------Capacity-----------------------Size--------------------------------Liquid depth------------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- Size: Diameter ------- ----------Dep th---------------- ---------------------------------- ❑ • ----- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- ID Distance to nearest lot line------------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining/material-------------------.---Size: Diameter-/---------------------Depth----------------------------- -- Disposal Field: ' Distance from nearest welI Distance from foundation--_-,41________-Distance to nearest lot ling-_-7___--_ J Number of lines______________ _ Length of each line:____--_-74___ ___-__-_Width of trench---.�-_;V___ _ _- Type of filter material- - __ Depth of filter material-------- ---.- Remodeling and/or repairing (describe):---------------- -_ - -_ -- _�±-___--- --___.- - -- -` -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_.------------ --------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- - hereby certify that I have pared this application and that the work will be done in accordance with San Joaquin County ordinances,Sfa+e a rule nd regulations of the San Joaquin Local Health District. �__ _ _ - Owner and or Contractor(Signed)----- ------- - ----------- -------- -� _ _-_ - BY:-----------------------------------------------------------------------------------------------------------------------------------{Title)---- - - (Plot 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----- DATE 4 V(/REVIEWEDBY -E;Y - - ----- - - - - ------------ DATE------------------- - - -- ---- ---------- BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE-------------------------------- - ------------------------ Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- PERMIT No._ __--- ISSUED--__ -- --- ! --- -----(Date) FINAL INSPECTION BY:---_-----1/v_-- - -----__----------------------- Date----------------------- _-- !}----/------------------•-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-21A 9-50 W-1639