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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. 1 This application is made in compliance with County Ordinance No. 549. 3 9 ---------------------------------------- = ,=- -------------------------- JOB ADDRESS AND LOCATION_______________ Owner's Name---- = ------- ---------------- Phone--- ---------�=-��-r Address---------------------------- ----- ------------------------------ - - , ---------- -- - Confiractor's Namem or✓c. . Phone------------•---------------------- ----------------------------------------------- Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court Motel ❑ Other ❑ Number of living units: M Number of bedrooms W Number of baths IN Lot size-------{__ Q_-. __1 --------______________________ Water Supply: Public system ❑ Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel 171Sandy Loam El Clay Loam❑ Clay ❑ Adobe Hardpan ❑('_ 1 -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--__________-__.______-.____-.._______________- t ❑ h No. of compartments Capacity Size 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----------------------Lininrg material-----------------------Size: Diameter-----------------------.Depth--------------------------- / Disposal Field: Distance from nearest well ^______-Distance from foundation___________________Distance to nearest lot lin _,` ______ Number of lines---------- -- -----------------Length of each line-------��-- ------------Width of trench----- ------------------- Type of filter material---- of filter material_-- _-If__-_---_ ------------------------------------------------------------- Remodeling and/or repairing (describe):-- ---------------•------------- ---------- -- - - ---- nv t T �Ttq c.. �/�� j----- - ------"-------------------------------------©------- -,---------------------------•----- ------------------- --- - ---------- ---- ---------------------------------------------------------------------------------------------------------------------------------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) J --------------------------- ----------- ---•------------------------------(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_______ -- �---�----------------- ---------- ------------- -------------- DATE---------------- . REViEWEDBY------------------------------------------------------------------------------------------------------------------------------ , BUILDING PERMIT ISSIfED------------------------------------ --------------------------------------- ---- ----------------- DATE-------------------------------------- ------------------- Alterations and/or recommendations-------------------------------------------------------------------------------------------------------------------•------------------------------------------- ---- ----------------------------- -- ------ -- ------------- U�v 1..�. �o-------- --- ------ �-------�-t/ __ ; -------------------------- ------------------------------------------------------------------•---------------------------------------------------- ---------------------------- - ( ,(f f� PERMIT No------(�'�--�------ ISSUED----- _' _....�'�-----------(Date) FINAL INSPECTION BY;------ `�-------------------------- --1110-1X ----------------------- `" 1110-1-1--------------------------- Date----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639