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APPLICATION FOR SANITATION PERMIT <br /> (Complete in Duplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. S49. <br /> JOB ADDRESS AND LOCATI N_____/�-- <br /> --- ------ <br /> Owner's Name (tom' ' ,9S W,Y� ----/------------------ - --------------------------------------- Phone------------------------------------ <br /> AddressI 3 I a ------------- -o-r q4�- -:<-------------------------------------------------------------------------------------------------------- <br /> Contractor's Name------------------------------------------------------------------------------ ------------- -- ----------------------- Phone----------------------------------- <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑r Other <br /> Number of living units:.•d Number of bedrooms 4 Number of baths ❑ Lot -------- ___________Water Supply: Public system N Community system ❑ Private [❑ D <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ <br /> 1 <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material----------------------------------____.__ _---- <br /> ❑ No. of compartments--------------------------Capacity-----------------------Size---- r -----------Liquid depth ------ , <br /> Distance from nearest ell___ -.Linin material__ ---- <br /> Cesspool: <br /> �_.____-Distance fr6m foundation_.__ g � � X <br /> xSize: Diameter---�- ----------------------Depth---------------------------------------------------- <br /> 1 'Privy: Distance from nearest well________________________________________________Distance from nearest building------------------------------------------ <br /> F1 Distance to nearest lot line________________________________________________ <br /> Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line___-____________ <br /> ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-------.----------------Depth-------.---------_-----------_--- <br /> ...Disposal Field: Distance from nearest well------------------Distance from foundation-------------------.Distance to nearest lot line_-_-_ �____ <br /> ❑ Number of lines-----------------------------------Length of each line------------------------------Width of trench_---------------------------------- <br /> Type of filter material_________________________Depth of filter material-___________-------.___ <br /> k <br /> Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State laws, and rules and'Qeegulations of the San Joaquin Local Health District. <br /> • t <br /> (Signed)----- -- -----�{, -- ------- --------------------------------------------------------------------------(Owner and/or Contractor) <br /> By:---- ---------------------------------------------- ---------------------------- ------------------------------------------------(Title)---------------------------------------------------------------- <br /> (Plot plans, showing size of lot, location of system in relation to wells, buildings, etc., must be filed with this application). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY----------- - a ------------------------------------------ ---------- DATE- _I l Z-Vf 1 <br /> REVIEWEDBY------------------------------------------------------------------------------------------------------------------ ----------- DATE----------- - <br /> BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE <br /> Alterations and/or recommendations---------------------------------- ------------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -----------------------------rr--��----yy-----------------------------------/67/ <br /> -------------------------------------------------------------------------------------------�---------------.------------------------------------ <br /> PERMIT Nd f_ ------- ISSUEDJZ8 __------_ INSPECTION <br /> -____--(Date) FINAL BY:-----:-- -- - - - -----------------------..--- <br /> Date----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street <br /> Stockton, California <br /> ES-9-2M 9-50 W-1639 <br />