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3�3 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 withhf County Ordinance No. 549. JOB ADDRESS ANJD LOCATION--- d�_ ______ _ Owner's Name ,-_• 4- --------------------------------------- - ------ ------ Phone------------------------------------ Address ' " ---------------------------------------------------------------------------------------- ------------------------------ Contractor's Name" ,/ - --4. f ------------------------------------------------------------- Phone-9—T --------- Installation will serve: Residence 10 Apartment House ❑ Commercial [] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: t] Number of bedrooms Z Number of baths Lot size-_- Wafer Supply: Public system Nd Community system ❑ Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe$ Hardpan El'sq` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) a Septic Tank: Distance from nearest well---'-fix+_-_Distance from foundation_.__®,___ Material_____19 _____________._ No. of compartments________--_ -- �•---•- -----Ca Capacity----X41-------Size----�`5-�-r'--� .��-- p Y - -- ------------ ----Liquid depth--�� ------------ . Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material--------------------.-_______________- ❑ 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__-______________ i ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Dept h--------------------------------- Disposal Field: Distance from nearest well__ _____.Distance from foundation___ '. ��___- ________Distance to nearest lot Iine__,ErQ�____ s g --.Width of trench------• Number of lines____________ _ ________________Length of each line______-__ Type of filter material__! , -_�'= 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. (Signed} = --- -------•- ""-"- =------------------------------------------ - {O�► "�Tii!/our Contractors --- ---- (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------------- -� z REVIEWED BY ------------------------------------------------------------------------ DATE BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE -Alterations and/or recommendations:----------- ----------------------------------------------------------------------_-------•--------------------------------------------------------------------------------- ------------------------------------ ------------------------------------------------------------ --------------------------------------------------------------- -------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- --------- --- --- ---------------- ---------------------------------------------- ---- --- -- PERMIT No.__- -� --------- ISSUED------- �___�s,57---_-------(Date) FINAL INSPECTION BY------- --- --- 4 --------------- Date------------------------ SAN --------------Date------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W=1634 \ �