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— Aft" . 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_______-:--- --------__-_ - J --- Owner's Name----------- ---- - :- - ------------------------------------------------------ Phone----- Address ` ac- �P- >------------- ---------------------------------------------------------------------------------------------------------------- Contractor's Name--------------- ------------------------------------- ----- Phone r Installation will serve: Residence Apartment House ❑ Commerciaf ❑ Trailer Court ❑ Motel ❑ Other 4 Number of living units: Number of bedroomsNumber of baths E] Lot size__ ____ ----f Water Supply: Public system [—] Community system E:] Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ V TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t Septi ank:' Distance from nearest well____________ Distance from foundation__________________ Material__________-_____- �I No. of compartments--------------------------Ca Capacity-----------------------Size------------------------ p Y -------Liquid depth -------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material------------------------------------- El _________________________________ _❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_----_--.________________ ❑ Distance to nearest lot line Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line_______--_----_-_ ❑ Number of pits----------------------Lining material----------------------_;Size: Diameter------------------------Depth------------------------------ --- iametr----------------_-----.Depth------------_-----------------_-- Disposal Field: Distance from nearest well_-S-0-_- _,Distance from foundation-- 9y_________-Distance too, nearest lot line--------------- Number of lines --- �� 1 ____ ___�!__ Length of each line_____ 4 F trench______ Type of filter mat, �_�-----NK-_Depth of filter material___--_ _1F x Remodelingand/or repairing (describe):-------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------- ` 1 I 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) ------ x`'----- - (Owner and/or Contractor) ----------------- ---- - �4 -----------------------------------------(Title)---------------------------------------------------------------- (Plot plans, showing size of lot, I cation of system in relation to wells, buildings, etc., must be filed with this application). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- -------- ---------------------- ----------------- DATE----------- - ------]_- - REVIEWEDBY--------------------------------------------- -------------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterationsand/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- ---------------------•------------------------------------------------------------------•-------•------------------------------------------•----------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ xI r PERMIT No------------------------- ISSUED------------------------------------------(Date) FINAL INSPECTION BY:---.---- DateL-,l_. = ?------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1639