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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) l Application is hereby made to the San Joagpin 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. t JOB ADDRESS AND LOCATION-------- �{--- --------------- rb/- " " - ----------------------------------------- ---- ------------- llIll Owner's Name A-V--_2---- --= ----V--H--4-- - •ids/ , ------------------------------------------ Phone _, ------ Contractor's Name____ ----------------------------------------------------------- Phone_ Installation will serve: Residence A Apartment House ❑ Commercial ❑ Trailer Court ❑ Mosel ❑ Other ❑ Number of living units:A -Number of bedrooms Number of baths :k Lot size___ O" y ,�- .�,_ Water Supply: Publics stemXY.50- ---------------------------- Character ❑. Community system ❑ Private Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe X 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 ________"____- _ r - ---------- Size----------------------------•--Liquid depth-------------------------- Cesspool• Distance from nearest well_________________Distance from foundation--------------------Lining material_-___--_-_.__-__________ ❑ Size: Diameter----i -------•----------------Depth-------------------------- --- ---- ------ Privy: Distance from nearest well------------------------------------------------- Distance from nearest building_______"__-____"____" ❑ Distance to nearest lot line_ -- ""------ -------- �Seepage ----------------------- Pit: Distance to nearest we I_-___---KQ__-___Distance from foundation__- Number of pits__________ __" Lining material___ ' -..Distance to nearest lot line___-_- .......- � - Size: Diameter__-__3_4 Depth •y Q---`---------; -Di, osal Field: Distance from nearest well_____ '�_^__ Distance from foundation___.'&�_---------Distance to nearest ]of line________________ TNumber of lines-------------- --------------------Length of each line------'_-__-------------------Width of french-------------'-...................... ype of filter material-------------------------Depth of filter material -----------------____-- Remodeling and/or repairing .(describe) - '` a - -----------------------------------------F ------ --------------------------- ---------------------------- ----------- - --------------------------------------------- --------------------------------------------------------------------------------------- ---------------------------------------------------------- -------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat an ul and regulations of the San Joaquin Local Health District. (Signed)--------- ------------ -------------- ----- -------------------------- -------------------------------------------- BY= = ------ ------------------------------------------------------------------------------(Title)------ � Contractor) er-and/or C or) (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_ __„(„ -_ D �/J ��}} ---------------------------------------------------- ATE- REVIEWED BY ---------------------- ----------�3-------------------------------------------------------------- � r DATE_-------- ---------- ----------- . ------ •- --------------------- BUILDING -- ------ --.------BUILDING PERMIT ISSUED------------ ----------------------- -- - ----------------------------------------I_-DATE------------------------ Alterations and/or recommends+ions:____!_________________ ---------------------__�_ --------------------------- ---------------------- --------------------- ----------------------------------------------- --------------- - PERMIT No--- ----------------- ISSUED---------- �s�-------(Date) FINAL INSPECTION BY-------- N -- _ • Date_ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ES-9-2M 9-50 W=1639 Stockton, California Z