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lw APPLICATION FOR SANITATION PERMIT O lt (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 compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATIONk�- ---------------------------------------------------------------------------- Owner's Name----------------------------------------�r -"— So? A- ------------ Phone_.�--7A"� ------------- Address---------------- ------ 6- �-- - - -- Contractor's Name------- ----=- 1 -R�1� -------=_ts.if ----------------- Phone---, Installation will serve: Resident Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. '11- Number of:bedrooms %?-�Nurjber of bpths Lot size___�Q _x�-_� _.r�-----------------________ Wafer Supply: Public syste Community system rivate ❑ = { Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ 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--------------------------------------Depth-----------------------------=---------------------- l 'Privy: Distance fromnearestwell--------------------------------------------------Distance from nearest building----------------------------_-------_---- ❑ Distance to nearest lot line______________________________________________ Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line_________________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h-------------.------------------- _Disposal Field: Distance from neare t.welili�_---_Distance from foundation!-�_________-Distance to nearest lot line__�_�----_ Number of lines__________ Length of each line___ --------------- �� - --- -- g •r--- Width of trench---��---------------------- ly Type of filter material_�#y - ---Depth of filter material________�{� ___:_ Remodeling and/or repairing (describe):------- ------- ---_-- --------------------------- -- -,-_-_-- - ------ -- = �� ordinances, 5f a laws, P- nulation . the Sa Joaquin Local Hea!hereby certify ththis ap tion"an that the work will be done in accordance with San Joaquin County th District. (Signed)----- _ ---- ------ Contractor)------------- -------- ------- -- --- -- By:----- --- ----------------------------- ---- ;- ---------F--------------------------(Title) ----- H--C�,�%.j--------------------- (Plot plans, s wing size of lot, locatio of system in relation to wells, buildings, efc., must be ee with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ - ------ -------------------------- ---------------------- DATE------ REVIEWEDBY--------------------------------- -- - - -- -- --------------------------'---------------------------------------- DATE------------ BUILDING PERMIT ISSUED--------------------- -------------------- ----------------------------------------------------------- DATE------------- Alterations and/or recommendations--------------------------------- '----------------------------------------------------------------------------- �------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------- --------------------------------------------------------------------------------------------- ----- -- -- --------- ----- ---- PERMIT N,-A___7-_,'--- ISSUED---- _�-_ _ __Q __(Date) FINAL INSPECTION BY:______ Date----------------------------- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES--9-2M 9-50 W=1639 -