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APPLICATION FOR SANITATION PERMIT o� <br /> (Complete in Duplicate) <br /> J <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described, <br /> Thisapplication is made in compliance with County Ordinance <br /> JOB ADDRESS AND LOCATION f�P__�')__�___ G11_s�?0 <br /> Owner's Name----------------------------------------------•--- . -�------- ------------- ------------ <br /> Address----------------- ---------------------------------------------- <br /> Contractor's Name-------------•----------------------- <br /> Installation will serve: Residence Eg partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: V Number of bedrooms A- Number of baths [A Lot size-------- jCl -)----------------------- <br /> Wafer Supply: Public system Community system ❑ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted ifbl���J is available within 200 feet.) <br /> Septic Tank: Distance from nearest well - --------Distance fro foundation__/_�_________-MateriaL____�` ___ __ �---- <br /> No. of compartments_-_______�_______Capacity__X40________5ize�SGU__"A?1_iquid depth_Cil ----__________ <br /> Cesspool: Distance from nearest well-----------------Distance from foundation-_-.---------------.Lining material___________________________-----___. <br /> ❑ Size: Diameter--------------------------------------Depth----------------------- <br /> Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- <br /> F-1 Distance to nearest lot line------------------------------------------------ <br /> Seepage <br /> ___________________________________________ _Seepage Pit: Distance to nearest el _t07lr_ fance fro fo ndation___ <br /> __�_ �- ___ _'__.Distance to nearest lot line___`d <br /> '� Number of pits______________________Linin material._- r _Size: Diameter____ 3��Deptk�—__ -- � - _,. '_ - <br /> ._Disposal Field: Distance from nearest well_+Tgw_______Distance from foundation___ -------Distance to nearest lot line---13_-_____ <br /> Number of lines_________ ft_ _ ________Length of each line___�_________ ____Width of trench__a2_�!�________________ <br /> N <br /> Type of filter maferialI __ _ ________Depth of filter material------/ __. .-__ <br /> I <br /> Remodeling and/or repairing (describe): -----------------------------------------------•------------------------------- <br /> ------------------------------- ----- L r1_�' 1 �4 Q- ---------------------------------------------- <br /> ------------------------------------------------------------------------------•---------------------------------------------••--------------------------------------------------------------------------------------------- 1 <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> hereby certify that I hay repared this ap 'cation and that the work will be done in accordance with San Joaquin County + <br /> ordinances, State laws, and r es and regulati ;:Ia, Joaquin Local Health District. <br /> (Signed)--------------�1____t �5_--1-__ __rw__ wMjLer Contractor) <br /> - ---------------------------------------------------------- - - <br /> BY� �`� {Title) � n.C ------------------------ <br /> (Plot plans, showin size of lot, location system in relation to wells, buildings, etc., must be fi ed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY------------ -- ------ -•-- -------- - ------------------------------------------ DATE <br /> REVIEWEDBY----------------------------------- -- - - - ------- -- -------------- ---------------------------- -DATE-- 4 <br /> BUILDINGPERMIT ISSUED --------------- -------------------------------------------------------- DATE-/--------------------------------------------------------- <br /> Alterationsand/or recommendations-------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------- -------------------------------------•------------------------------------------------------------------------------------------------.--------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -------------------------------------------------------------------- <br /> s <br /> PERMIT NoJ_ 0`'d__y___ ISSUED______________ _�_IlDate1 FINAL INSPECTION BY:_ <br /> f -------"_ --_-__ /(Date) l____��� <br /> Date-------Z '�' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 2 <br />