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c � � � h iii!lllllllly 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 Ordnance No. 549. �J^ F Gt. /JOB ADDRESS AND LOCATION------------ `/------ Owner's Name-------------------------------- ---- ----------- - Phone- -------------------------- --------------- A ------------------------------------------J ' -12 `-v --------------------------------------------------------------------------------- ' -Contractor's Name------------------------------------��r �� G�/f� �' ------ Phone----------------------------------- Installation ------------------------------- -Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: T1 Number of bedrooms ❑ Number of baths ❑ Lot size________________________________________--__----------_-----� Water Supply: Public system ❑ Community system M Private [?� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ l., TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet.) Septic�T Distance from,nearest well_--'�0------Distance from foundation-__-1 -___--.Material-------- -�------• � ----/-------------- Lam. No. of compartments------------ ��----Capacity---��.---._--Size-----------------------•--------Liquid depth--------` `--__--------. Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----___________________.__.---_---_. ❑ Size: Diameter--------------------------------------Depth--------------------------------------------------._ Privy: Distance from nearest well-------------------------------------------------Distance from nearest builcling----------------------------------------- El Distance to nearest lot line------------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line--._________-__ ❑ Number of pits---------- -------Liningf material-----_'-----------------Size: Diameter-----------------------Depth---------------------------------- -Disposal _----_----_------ •------_Disposal Field: Distance from nearest well_--' _----Distance from foundation____________-Distance to nearest lot IVne____'�_______ �. Number of lines------------------ - Length of each line-------_-------1?___ ---.Width of trench------------------------------ Typo of filter material___ ;,-Depth of filter niaterial---------LV-_ }N,_ Remodeling and/or repairing (describe):------------------------------ `- ----------------------------------------- --------------•--- iwe ----------- � ------------------------------------------------------------------------------ ---------------------------------------------------. ------------------� - -_-------------------------------------------------------- I hereby certify that 1 have prepared this application�and�fhat the work will be d6ne,in accordance with San Joaquin County ordinances, State laws, and rules and regulations of Ae�Sa Joaquin Local Health District. (Signed} c- ------------- -------------- ---------------------------(Owner and/or Contractor} BY: =- ------------------------------------------(Title)------------------------------------------------------------ (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-------------------- _ DATE______.______-3_ 1_ _3- REVIEWEDBY BY---------------------------------------------------------=------'----------------------------------------------------------- DATE-------- ------- BUILDING PERMIT ISSUED---------------------------------------------------------------------I --------------------------- DATE----- - ---------- ----------------------------- Alterations -- - Alterations and/or recommendations-)---_ r s �i_�? l` %----------�-------- ------ -� ±isa --------------------------------------------------- - ----- -" --r ----- ---------- -- ------------------------------------------------------------------------------------ --------------------- ------------ --------------------------------------------------- ----------------------------------------------------------- --------------------------------------------------------•----------------- ---------------------------------- PERMIT No-------- - --------- ISSUED--3- -/_- --,Sf------------(Date) FINAL INSPECTION BY--------------.+/x/_------------------------------------------- Date 1414 - --- ------------------- .r Date-------------------------�------ , - ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=t639