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APPLICATION FOR SANITATION PERMIT 7. (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 compliancewi h County Ordinance No. 549. y�{/P/� __________ JOB ADDRESS.AND LOCATION____---------- - ---- - t---------- Phone ------------------------- Owner s Name--21-• - -- - --------- --- - - 6 f-ff__ ___ ______-_ ____ ____________________________________________________________________________________________ Address______.-____. ------------------ � _ �- ------------------ ------------------------- Phone----------------------------------- Con+rac+or's Name__________ —�""� �----- - -----�"" ""-- Installation will serve: Residence [j/ Apartment House ❑ Commercial El Trailer Court ❑ Motel ❑ Other El Number of living units: 0 Number of bedro ms� Number"of_ baths (, Lot size------- �i� -------------------------- Water Supply: Public system ❑ Community system ❑ Private E44ii Character of soil to a depth of 3 feet: Sand ❑ Gravel El Sandy Loa`❑ Clay Loam Clay ❑ Adobe❑ Hardpan ❑ it Ilk TYPE OF INSTALLATION AND SPECIFICATIONS: It (No septic tank or cesspool permitted if public sewer is available within 200 feet.) W SeXticTank. Distance from neares+ wele from foundation_____�_a_______.Material_______ssp -- Liquid depth--------------------------No. of compartments._._________-)-------Capacity____ ---Size___ C - I: Distance from nearest well________________Distance from��oundn _ ation___:_______________.Lining material ❑ Size: Diameter--------------------------------------Depth-------------------`---y------------------------- nearest well______________"_____,____________"_____ ___Distance from nearest building------------------------------------------ .Privy: Distance from ❑ Distance to nearest lot line------------------------------------------------- - S 'Seepage Pit: Distance to nearest well-------_--------------Distance from foundation--------------------Distance to nearest lot line____________--___ ❑ Number of pits----------------------Lining material-------------------I -Size: Diameter-----------------------.Depth------------------- Z _-Distance to nearest lot line___5_A�. Di osaj Field: Distance from nearest well _ ____.Distance from foundation___"___�_____ �1 0 �� - - Number of lines---------- ---------- --------Length of each line___:.:- -_ ---------.Wid#h of trench------------_-""-- Type of filter material.--" �--------Depth of filter ma terial______��-_-___-___ Remodeling and/or repairing (dest�ribe):_____________________"_______"______________.------=--------------------------------------------------------------- e N -------------------- -------------------------------------------------------------- ------------------------ ---------------------------------------------------- ---"---- ----------------------------------------------- ---------------------------------I--------------------------------------------------------------------------------------------------------------- -- --------- ----------------=--------------------------------------------------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law , and r les and regulations of the San Joaquin Local Health District. (Signelo(d) 17 (Owner and/or Contractor) ____Title By: -------------•------------ (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 {= - ------------ : REVIEWED BY--------------------------------=-------- ---------� ---------- •---------------------- ------------ -------------- - DATE------------------------------------------------------------ BUILDING PERMIT ISSUED--------•--------------------------------------- --------------------------� ------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations-------------------------- ------------ ----- -------------------------------------------------------------- -----••-•----------------------------------- --------------------------- --------------------- ------------------I----------------------- ---------------------I------------------------------------------------------------------••----------------------- 3 rr �°S? �. 1 PERMIT Na."""-- "_--- ---' (Date) FINAL INSPECTION 8Y:__-__-- -_"--- -, - IS5UED �L �" ,,,,.- ------ ------- -------- � �, - „Date------------------•----- ------ � - --------- -- k SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California E5-9-2M 9-50 W-1639