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l 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 tie JOB ADDRESS AND LOC T -_-_-_-_-- _ t'� = o� / ---- ---- ------------- -�------------------------ ---------------------------------------------- Owner's Name ------------------------------------ ---------- Address ------ 1Phone Address------------------------------------------••------------------------- - --------------------------- —.-------------------------------- ---------------------------------------Contractor's Name Name-------------------------•-y---- - moi/ - --- ----------- - -------------------- - . --------------------------------- ------------- Phone------------- ---- -- - - Installation will serve: Residence El/Apartment House ❑ Commercial ❑ Trailer Court ❑ //Motel ❑ Other ❑ Number of living units: Number of bedrooms VJ Number of baths ❑ Lot size_____- -47_- ------ 4-b__- ---- --------------------- Wafer Supply: Public system ❑ Community system ❑ Private 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 sewer is available within 200 feet.) Septic Tank.' �G Distance from nearest well-----------------Distance from foundation--------------------Material -___--___-----------____-------____--_---____---. ❑ 15x1,47,No. of compartments-------------------•------Capacity-----------------------Size----------------------------•---Liquid depth------:------------------- Cesspool: � Distance from nearest well-----------------Distance from foundation--------------------Lining material---------_--------------__-._ ❑ Size: Diameter------------------------------------Depth---------------------------------------------------- Privy: -------------------- -----------------------------Privy: Distance from nearest well------------------------------------------------- . ------------------Distance from nearest building---.----.------_-----------------_-------------------------------------------- ❑ Distance to nearest lot line________________________________________________ 1 Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------------Distance to nearest lot line___-_____---_--_ ❑ Number of pits------------ --------Lining material--:-- ------------------Size: Dia et r�---------------------Dept h----------------------�-y ti ;_Dis osa Field: Distance from nearest well ____-----Distance from foundation____ Distance to nearest lot line`______________ Number of lines_:_._ -_/- ' -! _ Length of each line____---- _ __ __-__-Width of trench_----- x __-_____________ Type of filter matenal_A�.___ .1-_-_Depth of filter material-----___-�r ;. -Remodeling and/or repairing (describe)---------------------------------------------------------------------------------------------------------------- - - i ----------------------------•------------------------------------------------ •------------------------•--------------------------------------------------------------------------------------------------------------- ---•------------------------------------------------ ------- --------------------------------------------------------•-------------------------------------------------------•--------------------------------------- ---------------------------- --------------------------------------------------------------•---------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sfafe laws, and rules and regulati -of the San Joaquin Local Health District. (Signed) y -------Owner and/or Contractor By—--------------------------------------------------------------- ---------------------------------------------------------------(rfle)---------------------------------------------------------------- i (Plot plans, showing size of lot, location of system in relation to wells, buildings,- efc., must be filed with this application). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __! f DATE_ — ------------- _ REVIEWED BY---. __ - DATE- ------------------------------------ BUILDING PERMIT ISSUED------ ------------------------------------------------------ ---------------------------------------- DATE------------------------------------------------------Alterations and/or recommend afions:--------------------------------------------- ----------- ---------------- je: - -------------- ----------- ---- - - --- a :Ic3- `a ---- ---------- ---------- ---------- r PERMITjCTION BY:ISSUED_-------- ---- ---- -- Date) FINAL INSPE - _ - Date--------------- �-- SANJOAQUIN LOCAL HEALTH DISTRICT J I, ,- 130 South American Street ,. � ' Stockton, California 1 ,- ES-9-2M 9.50 W-1639 -