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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) f 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. 4 r 1 Z/ - " JOB ADDRESS AND LO ION---------- -Z C_ - -f"� --------- -- -� --------- �- -�------------n'------ ----� r Owner's Name----------- -----�`- - -�-------- --- -- ----- ---"-- --- - - -------- Phone------------------------------------ Address-------------------------Q-` -----� ----- F Contractor's Name--.--... o- lG ��_--•. � a-�_'�-_r�_ --- '� ----K� ' ------------------------------ Phone------------------------------ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths ❑ Lot size__________________________________________________________ Water Supply: Public system ❑ Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan TYPE OF INSTALLATION AND SPECIFUGATIONS: (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: -- -_.Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_________________: ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well------------------------------- ------------------Distance from nearest building-------------------- ❑ Distance to nearest lot line________________________________________________ I ti;e• Pi : istance to nearest well---- ._-_O__�____ Distance from foundation--------------------Distance to nearest lot ❑ Number of pitO_..------T--------Lining material__ __Size: Diameter_____6_of__________.Depth______-! s Disposal Field: Distance from nearest well-----------------.Distance from foundation--------------------Distance to nearest .Width of=tre chy.. - ., IJ Number of lines------------------_----------------Length of each line______ _ _______ _._------- ----------------------------------- Type - Type of filter material-------------------------Depth of filter material_______________________ fl Remodeling and/or repairing {des ribe)--------------4----- ` - I -- -- 1 - --------- ------------------------------------------------------- ------------------------------------------------------------------------------------------ ----------------------------------- �- I hereby certify trh t I �e p pard this application and that the work will be done in accordance with San Joaquin County ordinances, Sta'fe laws an 4-ul and' regulations of the San Joaquin Local Health District. (Signed)..........., ...- ------ -------------- -----------------------------------------------------------------------------(Owner and/or Contractor) By: -- (Title) ----- ---- - ------- -----------•------------------------ (Plot plans, showing size of lot, location system in re'ation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------------------------------------------------------------------- DATE------------------------------ ---------------------------- REVIEWED BY-----------------•---------- --• --•-- -------------------------------------------------• DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------`----------------------------------=-------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations-------------------------------------------- �-----•----------------------------•------------------------------------------------------- --------------------------------------------------------------- ----------------- '�' " ----- - ------f6v------ — �- -----------------------`---..........-------------------------------------------------------------------------- ----------------------------------------------------------------------------- ----------------------- tw,..y„ PERMIT No.......•----------------- ISSUED.:----------------------------------------(Date) FIINAL INSPECTION BY-11-114!--------- ---- -- "'"'------------- Date-------- ------•------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California E5-9-2M 9-50 W-1639