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1 6v APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Application is hereby made to the San Joaquin Locai Health D•rstrict 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____ _____ - ----------- ----- -- ------------------------------------------------------------------------------------------ Owner's Name------- ,----- -------------- Phone --------------------- -------------------------------------------- Address------------ :5"/---6 = ---------------------------------------------------------------------------------------------- ---------------- Contractor's Name________ '_ _ t_.. - - -------------------------------------- ----------- Phone ------------------------------------------------ --------------------------- --------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ (� Number of living units: -[I N ber of bedrooms 2. Number of baths X Lot size____.____ Q__ -f/_Q____•--__------ -_ (��} Water Supply: Public system Community system F-1Private ❑ -�1 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan'❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest welL__71.Qti _.Distance from foundation------1Q-------Material-----E% -C1_w/C� -- -------------------- r x No. of compartments '�� Capacity Otl 0- Size 3x S3G -------Liquid depth----- 5� --------- Cs ------ J Cssp L• Distance from nearest well-----------------Distance from foundation---------------.-__.Lining material -- Size: Diameter--------------------------------------Depth----•----------------------------- Primyr.-�- Distance from nearest well_____________________ Distance from nearest-buildin -------------------------- 4 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------_-------------_.Depth--------------------------------- d__�___.Distance to nearest lot line_-/-____�Q-.`� QI Field: Distance from,nearest well---- CQistance from foundation___ S `Number of lines_'-"__:�► ______________Length of each line________ _ " g 6-----------------Width of trench------- Q Type of filter material Z_ .---Depth of filter material____-__ Remodeling and/or repairing {describe):_____________________ _ ----•------------ ---------- ------------ ---------------------------------- ---------------------------------------•------------------------------------------- - - -------------------------------------------------------------------------------------------------------•-- l I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State Paws, and rules and' regulations of the n aquin Local Health District, L, (Signed)----- - ---- --- ---- - �_--- ------ By: __ s Owner and/or Contractor Plot fans s owing size of lot, location of system in relation to wells, buildings, etc., mus}Title)____________________________________•__-___-_ --_-------___---- ( p 9 be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---.----------------- ---- --- --------------------------------------------------------- > DATE--------------- REVIEWED BY ------------------ -------------- ----------- ------------ ------------ - ----------------- --------------- - -------------- DATE------------- --------- BUILDING PERMIT ISSUED-------------- --------------------------------------------------------------- -------- DATE ~F -------------- Alterations and/or recommendations------------------------------------------------------ �.v ------------------------------------------------------------ ---------------------------------- r ---------•----------------------------------------------------------------•----------------------------------•------------------------ - / 40 I` PERMIT Ncf _�--- ---- ISSUED------ ----` / ---------(Date) FINAL INSPECTION BY:------V_ ---__ VZ('- - _-__-- ----------- Date---------- ------------ f - ---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639