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APPLICATION FOR SANITATION PERMIT �---� (Complete in Duplicate) Application is hereby made to the San Joaquin Local Health This application is made in compliance with County Ordir6'K JOB ADDRESS Owner's Name - Address ----------- ame_Address_-_________ 1 Contractor's N District fora permit to construct and install the work herein described. i`ce No:"549. 4 ------------------------------------------------------------ ------------ --------------------------- -- -- Phone -- Phone----------------- ----------- Installation will serve: Residence V Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms 4 Number f baths $ Lot size_____ _ __ ______ ____------ Water Supply: Public system ❑ Community system ❑ Private[ f Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan [� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public Iewer is available within 200 feet.) Septic ank: Distance from nearest well___ ___Distance from oundation___-___� �____-Mp eri 1 ____ ___ __-11-11.\ No. of com artments_____________________Ca acity__R_-------Size_��_ )(2- Liquid depth_-----_ + p P Cesspool: Distance from nearest well ___-___________-Distance from foundation __________________Lini_ng material ___________-_________________________ ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------- Privy: ------------------------------------------------- Privy: Distance from nearest well ------------------------------------ Distance'from nearest building _________________---___________-____-____.r ❑ Distance to nearest lot line ----------------------'-------------------------- Seepage Pit: Distance to nearest well ----_________________Distance dfrom foundation ---______________ Distance to nearest lot line____________ ❑ Number of pits --- __________________Li ing material___ _-------- 1_____.Size: Diameter ____-_________________-Depth ____________-_-----________ _ Ll i 4 t p (_ m foundation_____ _________Distance to nearest lot I' -_____Dis os Field: Distance from nearest weli__ ____ Distance froNumber of'lines__________®1Length of tach }ine_______- _ Width of trench___________________{Type of filter materi�___-_�Depth -of filter material__'Remodeling and/or repairing (describe):---------------------------------- - -----------------------------------------------------------------------------------------------------------------------------------------------------------;----------------------------------- --------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ - '' ----------------------- -------------------------------------------- -------=---------------------------------------------------------------------------------------------------------------------------------------- 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, Sined AA 1 -- ....... -'� � - }a /---�----------------------------------------------------------- (Owner and/or Contractor) By----_---------------------------------------------------- I ------------------ -------------------------------------(Title)---------------------------------------------------------------- � Y (Plot plans, showing size of lot, 10' cation of system in relafion to wells, buildings, efc., must be filed with this application). s ! i I J FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-- ------------------------------ - ~----------------------------------------------------- DATE --------: -------------------------------------- -; # DATE f' = REVIEWEDBY------------- -! --- :------ - --- ------------------------- �'-- ----------------- BUILDING PERMIT ISSUED --------------- - _------------------------------------------------------ DATE_ ------------------- Alterations -------------- - / - / Alterations and/or recommendations---- ------------- --------------------------------------------------_----------_------------- % � vr,!_ =-= ----- ' f = ------------- } r_ '�bf Cr IL---- f� -- � r -------------------- ------------------------- . E -- -z.-:: -- -- - - ff i rj �Ff. - d� 6 a p.��Ii r p 1 ------- ----------------------------------------- ---------------------------- — 1±1- -- ' -- --- - L ---- --- ------------------------------------------------ — - `/------- ISSUED l-- (Date) FINAL INSPECTION BY:--------- -------- -- J --------- PERM IT No.__ �`� _� f rl-----------------------�J---- - Date----------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES --9-2M !-SD W=1637 i