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APPLICATION FOR SANITATION PERMIT (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 LOCATION------------------------ --------------------------------- --- -= ------- ------ f , �` Owner's Name '� ' fYV Phonek-_ - ��` `' ---==------ ------------------ ---- ---- Address = ---•-------------------------- `' fr -------- ----------------- ---------------------------------------------------------------- Contractor's Name_-------h__`---- = J - "�V(!r Phone-f- 1 ; Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: fl-I., Number of bedrooms,.f Number of baths a'_ 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 ['Z" Hardpan ❑ `-i 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-------------------------Caacit Size-------•-------------------.-_Liquid depth------------------------- Cesspool- Distance from nearest well_________________Distance from found tion------------------- Lining material-----------------------------__._- ❑ Size: Diameter--------•-----------------------------Depth---------------------------------------------------- Privy: Distance from nearest well__________________________---------------------Distance from nearest building------------------------------------------ F1 Distance to nearest lot lino-- -------------------------------------------- Seepage Pit: Distance to nearest well_____-------Distance from foundation__:-~-%-------Distance to nearest lot line__=_ _ .fl Number of pits___f ______Lining materials_ � ?_J"A',Size: Diameter_- -�_f f--_.Depth__-2-s:=��_ _ Disposal Field: Distance from nearest well_________________-Distance from foundation--------------------Distance to nearest lot line.----.___________ ❑ Number of lines-----------------------------------Length of each line-----------------------------Width of trenck------------------------------------ Type of filter material-______________________Depth of filter material_________________:___ Remodeling and/or repairing (describe):------------- - ' --------- �` A of i 1 -f__---� f_ f/n_---� ------------------------------------------------------------•----- --------------------------------------------------------------------------------------------------------------------------•------•--•----------------- ------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State,laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------= -r = = r ._.. ' '''_= _ f Y' _--_ ---- --------------- ----------- - `--(Owner a Contractor) n r o r By .� l" '`a" t ... Le - fi {Title) r--`- (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-------W ,U,d-------------------------------------------------------------------------- DATE---- REVIEWEDBY-----------•--------------------- 1,� v ------------------------------------------------------------------------- DATE-----Z ------------------------------------ � BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterations and/or recommendations:----------------------------------------------------------------------------------------------------•------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- PERMIT No---- ISSUED____, ------S'--/------(Date) FINAL INSPECTION BY:------- �______________ ------------------- Date------------ ----_Date--------------- f --------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639